October 9, 2019

REBEL Core Cast 19.0 – Acute Angle Closure Glaucoma

Take Home Points 

  • Acute closed angle glaucoma is an ophthalmologic emergency that usually presents with sudden, painful, monocular vision loss.
  • Physical exam will reveal conjunctival redness, corneal haziness or cloudiness due to edema and a pupil that is mid sized and minimally reactive to light, a rock hard globe and IOP >/= 21.
  • These patients require emergent ophthalmology evaluation but treatment should be started empirically while waiting for the evaluation. Initial treatment to decrease IOP usually includes a topical BB such as timolol and topical AB such as apraclonidine and either IV or PO acetazolamide.  


REBEL Core Cast 19.0 – Acute Angle Closure Glaucoma

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Show Notes

What is it? 

  • Group of diseases that have increased intraocular pressure (IOP) causing optic nerve damage leading to decreased vision
  • Different types of glaucoma
    • Open-angle glaucoma
    • Closed-angle glaucoma

Open-Angle Glaucoma

  • Most common type
  • Characteristized by progressive peripheral visual field loss followed by central
  • Likely because of increased resistance to aqueous outflow through trabecular meshwork
  • Patients generally have increased IOP

Closed-Angle Glaucoma

  • Worrisome pathology in the emergency department
  • Closing / Narrowing of the anterior chamber angle
  • Increased aqueous humor collection leads to increased IOP and damage to the optic nerve
  • Presents with sudden painful vision loss, red eye, halos, frontal or supraorbital headache 

Differential for Painful Red Eye

  • Corneal abrasion
  • Conjunctivitis
  • Subconjunctival hemorrhage
  • Iritis
  • Episcleritis
  • Infectious keratitis
  • Traumatic hyphema

Risk Factors for Glaucoma

  • Family history
  • Age >60 years
  • Female Gender
  • Far sighted
  • Medications (HCTZ, albuterol, SSRI, TMP-SMX among others)
  • Inuit & Asian ethnicity 

Eye Exam

  • Any person presenting with vision loss or eye pain deserves full exam
  • Visual acuity
  • Pupil exam
  • Visual field testing
  • Evaluation of IOP with a tono-pen
  • Slit-lamp exam
  • Fundoscopy

Physical Exam

  • Conjunctival redness
  • Corneal haziness
  • Mid sized pupil minimally reactive to light
  • Palpate eye – potentially “rock hard”


  • Consult ophthalmology 
  • Topical beta blocker – timolol
  • Topical alpha blocker – Apraclonidine
  • 500 mg IV / PO acetazolamide
  • Recheck IOP hourly, keep head of bed elevated, keep in bright room

For More on This Topic Checkout:

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 19.0 – Acute Angle Closure Glaucoma", REBEL EM blog, October 9, 2019. Available at: https://rebelem.com/rebel-core-cast-19-0-acute-angle-closure-glaucoma/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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