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Glaucoma, Emergency Medicine

Basics

Description

- Primary glaucoma: - Open-angle glaucoma: - Normal anterior chamber angle - Insidious onset with persistent rise in intraocular pressure - Most common type accounting for 90% of glaucomas in US - Leading cause of blindness in African Americans - Risk factors include African American, age >40 yr, family history, myopia, diabetes, and HTN

- Secondary glaucoma occurs from other diseases, including diseases of eye, trauma, and drugs: - Can be either open or closed angle - Drugs: Steroids, sertraline, bronchodilators, topiramate - Diseases: Neurofibromatosis, uveitis, neovascularization, and intraocular tumors - Trauma - Rapid correction of hyperglycemia

- Primary angle-closure glaucoma: - Severe deep eye pain and ipsilateral headache often associated with nausea and vomiting - Decrease in visual acuity often described as visual clouding with halos surrounding light sources - Associated abdominal pain, which may misdirect diagnosis - Concurrent exposure to dimly lit environment such as movie theater - Use of precipitating medications: - Mydriatic agents: Scopolamine, atropine - Sympathomimetics: Pseudoephedrine, albuterol - Antihistamines: Benadryl, Antivert - Antipsychotics: Haldol - Phenothiazines: Compazine, Phenergan - Tricyclic antidepressants: Elavil - Sulfonamides: Topiramate

- Primary open-angle glaucoma: - Primary angle-closure glaucoma: - Decreased visual acuity - Pupil is mid-dilated and nonreactive. - Corneal edema with hazy appearance - Conjunctival injection, ciliary flush - Firm globe to palpation

- Primary angle-closure glaucoma (ophthalmologic emergency): - Intraocular pressure reduction: - Topical β-blocker, timolol maleate, to decrease aqueous humor production - Topical α2-agonist, apraclonidine, to decrease aqueous humor production - Carbonic anhydrase inhibitor, acetazolamide, for reduction of formation of aqueous humor - Hyperosmotic agent, mannitol, to draw aqueous humor from vitreous cavity into blood (indicated for severe attacks).

- Emergent ophthalmology consultation for possible definitive surgical treatment, laser iridectomy, if no improvement with medical management - Adequate narcotic analgesia and antiemetics as needed

Disease characterized by elevation of intraocular pressure, optic neuropathy, and progressive loss of vision.

Etiology

  • Primary glaucoma:Open-angle glaucoma:Normal anterior chamber angleInsidious onset with persistent rise in intraocular pressureMost common type accounting for 90% of glaucomas in USLeading cause of blindness in African AmericansRisk factors include African American, age >40 yr, family history, myopia, diabetes, and HTNAcute angle-closure glaucoma:Narrowing or closing of anterior chamber angle precluding natural flow of aqueous humor from posterior to anterior chamber of eye and through its filtering portion of trabecular meshworkUsually abrupt onset with sudden increase in intraocular pressureRisk factors include Asians and Eskimos, hyperopia, family history, increased age, and female gender
  • Secondary glaucoma occurs from other diseases, including diseases of eye, trauma, and drugs:Can be either open or closed angleDrugs: Steroids, sertraline, bronchodilators, topiramateDiseases: Neurofibromatosis, uveitis, neovascularization, and intraocular tumorsTraumaRapid correction of hyperglycemia

Diagnosis

Signs and Symptoms

Classic descriptions:

  • Open angle:Painless and gradual loss of vision
  • Closed angle:Painful loss of vision with fixed midsized pupil

History

  • Primary open-angle glaucoma:Gradual reduction in peripheral vision or night blindnessTypically bilateralPainless
  • Primary angle-closure glaucoma:Severe deep eye pain and ipsilateral headache often associated with nausea and vomitingDecrease in visual acuity often described as visual clouding with halos surrounding light sourcesAssociated abdominal pain, which may misdirect diagnosisConcurrent exposure to dimly lit environment such as movie theaterUse of precipitating medications:Mydriatic agents: Scopolamine, atropineSympathomimetics: Pseudoephedrine, albuterolAntihistamines: Benadryl, AntivertAntipsychotics: HaldolPhenothiazines: Compazine, PhenerganTricyclic antidepressants: ElavilSulfonamides: Topiramate

Physical Exam

  • Primary open-angle glaucoma:
  • Primary angle-closure glaucoma:Decreased visual acuityPupil is mid-dilated and nonreactive.Corneal edema with hazy appearanceConjunctival injection, ciliary flushFirm globe to palpation

Essential Workup

  • Detailed ocular exam
  • Visual acuity:Hand movements typically all that is seen
  • Tonometry:Normal pressures are 10-21 mm Hg.Primary open-angle glaucoma:Degree of elevation can vary, but 25-30% of patients may have normal intraocular pressures.Primary angle-closure glaucoma:Any elevation is abnormal, but usually seen in ranges >40 mm Hg.
  • Slit-lamp exam:Evaluation of anterior chamber angleUsed to eliminate other possibilities in differential including corneal abrasion and foreign body

Diagnosis Tests & Interpretation

Lab

Directed toward workup of differential

Imaging

Directed toward workup of differential

Diagnostic Procedures/Surgery

Gonioscopy:

  • This is direct measurement of the angle of closure

Differential Diagnosis

  • Cavernous sinus thrombosis
  • Acute iritis and uveitis
  • Retinal artery or vein occlusion
  • Temporal arteritis
  • Retinal detachment
  • Conjunctivitis
  • Corneal abrasion

Treatment

Pre-Hospital

  • No specific interventions need occur prior to arrival at the hospital in regard to the eye:Pain control may be necessaryIn traumatic etiologies, stabilize other injuries

Initial Stabilization/Therapy

  • Initiate steps to lower intraocular pressure in acute closed-angle glaucoma:Address other effects of trauma if this was the etiologyDiscontinue inciting medication when involved

Ed Treatment/Procedures

  • Primary open-angle glaucoma:Recognition and prompt ophthalmologic referralPatients maintained on topical β-blockers or prostaglandin analogs to decrease IOP
  • Primary angle-closure glaucoma (ophthalmologic emergency):Intraocular pressure reduction:Topical β-blocker, timolol maleate, to decrease aqueous humor productionTopical α2-agonist, apraclonidine, to decrease aqueous humor productionCarbonic anhydrase inhibitor, acetazolamide, for reduction of formation of aqueous humorHyperosmotic agent, mannitol, to draw aqueous humor from vitreous cavity into blood (indicated for severe attacks).Movement of iris away from trabecular meshwork:Topical parasympathomimetic, pilocarpine hydrochloride, to constrict pupil once intraocular pressure is <40 mm HgReduction of inflammation:Topical corticosteroid, prednisolone acetateEmergent ophthalmology consultation for possible definitive surgical treatment, laser iridectomy, if no improvement with medical managementAdequate narcotic analgesia and antiemetics as needed

Medication

  • Acetazolamide: 500 mg IV or PO
  • Mannitol 20%: 1-2 g/kg IV over 30-60 min
  • Pilocarpine hydrochloride 1-2% solution: 1 drop q15-30min until pupillary constriction occurs, then 1 drop q2-3h
  • Prednisolone acetate 1% solution: 1 drop q15-30min for total of 4 doses

First Line

  • β-Agonists:Timolol maleate 0.25 or 0.5%:1 drop to affected eye BIDLevobunolol 0.25 or 0.5%:1 drop to affected eye BIDCarteolol HCL 1%:1 drop to affected eye BIDBetaxolol 0.25 or 0.5%:1-2 drop(s) to affected eye BID

Second Line

  • Adrenergic agonists:Apraclonidine 0.5%, 1%:1-2 drop(s) to affected eye BIDBrimonidine:1 drop to affected eye TID
  • Carbonic anhydrase inhibitors:Acetazolamide:Methazolamide:Dorzolamide HCl 2%:1 drop in affected eye TIDBrinzolamide:1 drop to affected eye TID
  • Prostaglandin analogs:Latanoprost:1 drop in affected eye QHSBimatoprost 0.03%:1 drop in affected eye QHSTravoprost:1 drop in affected eye QHSUnoprostone:1 drop to affected eye BID

Considerations in Prescribing

  • Prostaglandin analogs have become standard of care for open-angle glaucoma due to an improved side-effect profile
  • Due to cost, topical β-blockers are often still used primarily

Follow-Up

Disposition

Admission Criteria

  • Severe pain, nausea, or vomiting
  • Patients receiving parenteral medications should be observed for side effects.
  • Patients without improvement of symptoms or intraocular pressures should be admitted for continued monitoring of intraocular pressure, medical treatment, and possible definitive surgical management:Laser intervention is more likely than operative

Discharge Criteria

Patients with minor symptoms and significant improvement of intraocular pressure may be safely discharged once seen by ophthalmology and with close, <24-hr follow-up.

Issues for Referral

If no ophthalmologist is available, treatment should be initiated and patient transferred to nearest hospital with ophthalmologic consultation.

Follow-Up Recommendations

  • Open-angle glaucoma patients need urgent ophthalmology follow-up to optimize medical management
  • Closed-angle glaucoma patients need immediate intervention

Pearls and Pitfalls

  • Increased IOP can cause vascular insufficiency and with delayed treatment vision loss can be permanent
  • Eye pain/headache can be associated with severe abdominal pain-do not ignore the eye and miss the diagnosis
  • Patients maintained on topical β-blockers for open-angle glaucoma may present with systemic side effects including orthostatic hypotension, bradycardia, or syncope

Additional Reading

  • Chew P, Sng C, Aquino MC, et al. Surgical treatment of angle-closure glaucoma. Dev Ophthalmol. 2012;50:137-145.
  • Dargin JM, Lowenstein RA. The painful eye. Emerg Med Clin North Am. 2008;26(1):199-216.
  • Marx JA, Hockberger RS, Walls RM, et al. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2010.
  • M ¼skens RP, Wolfs RC, Witteman JC, et al. Topical beta-blockers and mortality. Ophthalmology. 2008;115(11):2037-2043.
  • Nongpiur ME, Ku JY, Aung T. Angle closure glaucoma: A mechanistic review. Curr Opin Ophthalmol. 2011;22(2):96-101.
  • Tse DM, Titchener AG, Sarkies N, et al. Acute angle closure glaucoma following head and orbital trauma. Emerg Med J. 2009;26(12):913.

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

  • 365.9 Unspecified glaucoma
  • 365.11 Primary open angle glaucoma
  • 365.22 Acute angle-closure glaucoma
  • 365.60 Glaucoma associated with unspecified ocular disorder
  • 365.31 Corticosteroid-induced glaucoma, glaucomatous stage

ICD10

  • H40.9 Unspecified glaucoma
  • H40.11X0 Primary open-angle glaucoma, stage unspecified
  • H40.219 Acute angle-closure glaucoma, unspecified eye
  • H40.50X0 Glaucoma secondary to oth eye disord, unsp eye, stage unsp
  • H40.60X0 Glaucoma secondary to drugs, unsp eye, stage unspecified

SNOMED

  • 23986001 Glaucoma (disorder)
  • 77075001 Primary open angle glaucoma (disorder)
  • 30041005 Acute angle-closure glaucoma (disorder)
  • 95717004 Secondary glaucoma (disorder)
  • 1654001 Corticosteroid-induced glaucoma
  • 21571006 Secondary angle-closure glaucoma (disorder)
  • 21928008 Secondary open-angle glaucoma