Slit lamp exam findings include conjunctival hyperemia, microcystic and stromal corneal edema, a shallow anterior chamber with cells and flare, iris bombé and a classic mid-dilated pupil. Patients with an acute angle closure attack will experience blurry vision with halos around lights, nausea, vomiting, headaches and severe eye pain. 1 Prolonged exposure to dim illumination or topical medications, such as tropicamide 1.0% or vasoconstrictors such as tetrahydrozoline 0.05% (found in Visine eye drops) may cause at-risk patients to develop an acute angle closure attack. Primary angle closure is more common in people of Asian or Inuit decent and usually occurs in female patients with hyperopia, shorter axial length and a thickened crystalline lens. Primary angle closure can occur by non-pupil block mechanisms as well, such as angle crowding from a thickened peripheral iris stroma, or plateau iris syndrome. This can occur acutely, causing an angle closure attack, or proper aqueous flow may be restored spontaneously, resulting in a subacute/intermittent or chronic disease course. As the iris continues to touch the trabecular meshwork, it can form peripheral anterior synechiae. As the peripheral iris bows forward, it makes contact with the trabecular meshwork and blocks the outflow of aqueous from the eye, leading to an elevated IOP. 1-3 Primary angle closure most commonly occurs when aqueous flow from the posterior to anterior chamber is blocked at the pupil by contact between the iris and the lens, leading to an increased intraocular pressure (IOP) in the posterior chamber and a forward bowing of the peripheral iris (known as iris bombé). If left untreated, primary angle closure glaucoma-a major cause of blindness worldwide-can occur and prompt intervention will be needed to preserve vision. A cute primary angle closure is an ocular emergency where hours can make the difference in a patient’s final visual outcome.
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