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Clinical Summary

Acute narrow or closed-angle glaucoma (ACG) results from a physical impedance of aqueous humor outflow. Symptoms range from colored halos around lights and blurred vision to severe pain (described as a headache or brow ache) with nausea and vomiting. IOP is markedly elevated. Perilimbal vessels are injected, the pupil is middilated and poorly reactive to light, and the cornea may be hazy and edematous.

Two-thirds of glaucoma patients have open-angle glaucoma. Often they are asymptomatic. They may have a family history of glaucoma. Funduscopy may show asymmetric cupping of the optic nerves. The optic nerve may show notching, local thinning of tissue, or disk hemorrhage. Optic cups enlarge, especially vertically, with progressive damage. Tissue loss is associated with visual field abnormalities. The IOP is often but not always greater than 21 mm Hg.

Management and Disposition

Acute ACG requires emergent ophthalmologic consultation and administration of medications to decrease IOP such as β-blocker drops (timolol), carbonic anhydrase inhibitors (acetazolamide), cholinergic-stimulating drops (pilocarpine), hyperosmotic agents (osmoglyn), and α-adrenergic agonists (apraclonidine). Open-angle glaucoma is treated with long-term ophthalmic evaluation and treatment with medications and laser or surgery.


  1. Nausea, vomiting, and headache may obscure the diagnosis. Use digital globe palpation routinely in patients with these complaints.

  2. Open-angle glaucoma usually causes no symptoms other than gradual loss of vision.

  3. Congenital glaucoma is rare. However, because of prognosis if diagnosis is delayed, consider congenital glaucoma in infants and children with tearing, photophobia, enlarged eyes, or cloudy corneas.

  4. Asymmetric cupping, enlarged cups, and elevated IOP are hallmarks of open-angle glaucoma.


Normal Cupping. The cup is central and is less than one-half the diameter of the disk. (Photo contributor: Jeffrey Goshe, MD.)


Glaucomatous Cupping. The cup is not central; it is elongated toward the rim superotemporally. (Photo contributor: Department of Ophthalmology, Naval Medical Center, Portsmouth, VA.)

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