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Q1: Describe the anterior segment photographs
Both eyes reveal ciliary injection, corneal oedema, and shallow anterior chambers. Both pupils are oval and mid-dilated along with patches of iris atrophy more prominent in the left eye (figs 1 and 2; see p 542).
Q2: What is the diagnosis?
Bilateral simultaneous acute angle closure glaucoma. An acute attack of angle closure glaucoma is normally associated with a very high intraocular pressure along with reduced visual acuity, oedematous cornea, and shallow anterior chamber. The intraocular pressure in this case is low in both eyes because of prolonged attack leading to ciliary body shutdown (shock). The ciliary body shutdown led to reduction in aqueous production and the iris atrophic patches signify prolonged exposure of both eyes to high intraocular pressure.
Q3: How would you manage this patient?
The most important point is to reduce the inflammation so that the antiglaucoma medication can work. The patient was started on prednisolone (0.5%) and pilocarpine (2%) eye drops in both eyes. On further follow up, the corneal oedema resolved and gonioscopy revealed closed anterior chamber angles in both eyes. On her last follow up her visual acuity improved to 6/12 and 6/9 in right and left eye respectively. Later a laser iridotomy was carried out in both the eyes.
Q4: What is the cause?
Bilateral simultaneous angle closure attack has been described in the past to occur with surgical anaesthesia1 and various drugs including paroxetine,2 bronchodilators,3 imipramine,4 and fluoxetine.5 Idiopathic bilateral simultaneous attack is a very rare entity. Saunders reported a series of 41 patients who presented with acute angle closure and only one had simultaneous bilateral symptoms of unknown cause.6 Our patient had no obvious cause and the onset of symptoms of bilateral angle closure attack was spontaneous.
An acute attack of angle closure glaucoma is normally associated with a very high intraocular pressure along with reduced visual acuity, oedematous cornea, and shallow anterior chamber. It is an ophthalmic emergency and warrants immediate systemic antiglaucoma medications—for example, acetazolamide or mannitol. Acute angle closure glaucoma can easily masquerade a systemic illness and these patients may present not only with painful eye with reduced vision but also with systemic symptoms and the diagnosis can easily be missed.7,8 These patients should be referred immediately to the eye department to prevent ocular morbidity from this potentially treatable condition.
Patients with acute angle closure glaucoma may present with systemic symptoms and reduced vision.
They should be referred urgently to an ophthalmologist to prevent ocular morbidity and blindness.
An acute attack may spontaneously resolve by causing ciliary body shutdown and iris atrophy and thus bringing intraocular pressure back to normal.
Idiopathic bilateral simultaneous acute angle closure glaucoma.