Good Hope, Heartlands, and Solihull Eye Clinics

Acute angle closure glaucoma

David Kinshuck



Acute glaucoma is caused by a sudden rise in pressure in the eye. It is often very painful, but is often easy to treat. This page describes the condition and the treatment. The are different types of acute glaucoma, but this page describes the commonest, acute angle closure glaucoma. Animation


Parts of the eye

anatomy of eye

anatomy enlarge

The eye is partly filled with a watery fluid, called 'aqueous'. The aqueous is produced in the ciliary body, in the 'posterior chamber' of the eye.

Then the aqueous flows forward into the anterior chamber, and leaves the eye in a the eye's drainage system.






aqueous flow through trabecular meshwork

The eye's drainage system: aqueous (green arrow) drains from the posterior chamber, to the anterior chamber, through trabecular meshwork, through the canal of schlemm, and out through the episcleral veins into the blood stream. (This has nothing to do with tears; tears cover the front surface of the eye only.)  enlarge


What is eye pressure?

aqueous flownormal aqueous flow enlarge

The eye is partly filled with a watery fluid, called 'aqueous'. The aqueous is made in the middle chamber of the eye. The aqueous flows forward into the front chamber, and leaves the eye in a the eye's drainage system, through trabecular meshwork, canal of schlemm, and out through the episcleral veins.

From the drainage system, the aqueous flows into the blood stream.

Thus normally aqueous flows from the posterior to the anterior chamber, then out of the eye.



What is happening in acute glaucoma

angle closure

The first blockage occurs (red blob) when the iris contacts the lens; this pushes the iris forward (pink  square) to obstruct the flow to the trabecular meshwork (yellow blob) enlarge  


First, the iris presses backwards on the lens of the eye. Every year the lens gets a little thicker, and so the gap gets narrower. Some drugs make the iris a little more rigid (Atrovent inhalers for asthma, some antidepressants). Animation

One day, perhaps when coming from a dark room to a light room, this blocks the flow of aqueous (red blob). This puts the pressure up  little.

Next, the pressure pushes the iris further forward forward (pink square).  Animation

And then this iris blocks the entrance to the trabecular meshwork drainage system (yellow blob).

Finally, as the aqueous cannot leave the the eye, the pressure in the goes up a lot, like a tyre being pumped up to much. This pressure is transmitted to the the optic nerve.
The eye becomes red and achy (see below). If the pressure is high enough for long enough the optic nerve becomes damaged (caved in or 'cupped') and the sight becomes damaged.

In acute glaucoma there are different shapes of the eye and the anterior/front chamber that contribute. Eye 17



mechanism of angle closure glaucoma



What do you notice?

The condition may develop gradually ('chronic'), as with most glaucoma, and there are no symptoms. The condition may be identified by optometry tests or other eye examinations. (Chronic narrow angle glaucoma). Later, there may be headaches or loss of sight, but by then some vision is lost.

In some people mild attacks of acute glaucoma may be occurring. There may be episodes of blurred hazy sight and slight eye pain or headache.

But in some people the attack is severe, the eye becomes red, the pressure is very high, and there is sickness and vomiting and severe pain in the eye. Urgent treatment is carried out in the eye department.   


A scan showing the condition

an ultrasound photo of the anterior chamber (Ophthalmology International)A B scan with a normal anterior chamber above, and  narrow angles below (Ophthalmology International). The iris is pushed forwards.

This top photo is a healthy eye.





This bottom photo shows that the iris is pushed up, 'bowed forward', obstructing the trabecular meshwork.





Initial medical treatment

This includes diamox (acetazolamide) tablets/injection, and eye drops. Resistant cases may need more treatment, such as an injection into the eye to drain the aqueous. All this treatment lowers the pressure, to resolve the attack of glaucoma.

Medical treatment

  1. intravenous diamox 500mg
  2. drops latanoprost, cosopt or azopt and timolol, (or just dorzolamide/azopt if asthma), Iopidine, pilocarpine 2%
  3. wait 30 minutes
  4. pressure should be dropping
  5. if pressure has not dropped at 30-60 minutes, proceed with anterior chamber paracentesis as below.

Anterior chamber paracentesis

  1. Local anaesthetic drops such as oxybupricaine
  2. clean eye with polvidone iodine 5%,
  3. wait a minute
  4. insulin syringe
  5. remove plunger
  6. insert in limbus at 9 o'clock if you are right handed
  7. aiming for centre of anterior chamber
  8. avoid lens!!
  9. aqueous should enter syringe to lower/normalise the pressure
  10. see

No response ..cyclodiode laser

If the pressure does not drop after the paracentesis, or goes up again, it is important to lower the pressure. Cyclodiode laser is the next step.   Eye12     15 spots ? see


Laser treatment 'PI': peripheral iridectomies

The hole made with laser enlargeiridotomy...the treatment of acute glaucomahole made with laser allows fluid flow out of eye enlarge
before, left; after laser, rightphoto of iridotomyphoto of an iridotomy...shown by yellow circle enlarge

See animation  Once attack of glaucoma is over, laser is needed to prevent the condition occurring again. PIs for professionals. Nearly always both eyes are treated to prevent an attack in the other eye.

The laser is called 'PI', peripheral iridectomy.

An hour before laser

Drops are needed to make the pupil small. These may cause a headache. Tablets keep the eye pressure down for the first day, and these can make patients feel a little funny, with pins and needles.

'Laser' is a type of very bright focused light.
The patients sit at the laser machine, then drops are used to anaesthetise the front of your eye, and a small contact lens is placed on the eye. When the button is pressed there may be a slight pain lasting a second or less.

The laser

The laser makes a tiny hole in the iris of your eye. The hole is invisible to the naked eye. Once the hole is made fluid can flow though to the front chamber and then out of the eye. This hole keeps the eye pressure down.

Week of laser

You need anti-inflammatory drops for 2 weeks (such as dexamethasone), as well as your regular glaucoma drops if you have any.
Occasionally the laser only goes half way through the iris, and you may need the hole completed a week or two later.

Month after laser

Many people do not need drops after 4 weeks, but some do.

Cataract/lens removal surgery

This is demanding with acute glaucoma. May be best treatment if none acute angle closure though) Eye 19


After laser, a few people may need drops indefinitely

Laser completely prevents an 'attack' of acute glaucoma, so this will never be a problem. Most people have the laser, are seen a month after, about 6 months later, and are later discharged to be followed up by their optometrist.

However, a few people with chronic angle closure glaucoma may still have a slightly high pressure even after laser, and they need drops indefinitely. Imagine an overflowing sink. If you remove the plug (with laser), there may still be a blocked drain (trabecular meshwork), or entrance to the trabecular meshwork (peripheral anterior synechiae).

Technically the blockage is in the trabecular meshwork, which is the drainage system of the eye. If you need drops you will be followed up in the outpatient clinic. If your doctor thinks you are lucky enough not to need drops, always have your eyes checked by your optometrist every year as a precaution. See animation.

About one third of patients will not need drops after laser. One third will need drops. Of the other third, some may need drops later. Some of the patients needing drops may need treatment for plateau iris, which includes laser iridoplasty or cataract surgery (our page).

After the PIs, patients should be followed up. This can be carried out by optometrists with special training in glaucoma, as then angles can narrow, so yearly gonioscopy is ideal.



Cataract surgery in angle closure glaucoma

iridotomy...the treatment of acute glaucoma Aqueous flow in acute closed angle glaucoma, left. Right, aqueous flow is restored after cataract surgery. Enlarge

Thickening of the lens of the eye (cataract) contributes to the angle closure. This happens naturally as we get older, but may happen earlier if we develop a cataract. As cataracts are common as we get older, (and more common in smokers), we are more prone to acute glaucoma as we get older. Some patients with unusually small eyes may develop it at a younger age.

If you have a cataract then cataract surgery will also prevent attacks of angle closure glaucoma. As cataract surgery is becoming safer ophthalmologists are starting to recommend cataract surgery for patients with narrow angles .

A normal cataract is about 4.5mm thick, and the lens implant is about 1mm, so there is about 3.5mm extra room for the aqueous to circulate.


Technique & problems

  • Cataract surgery is not usually indicated immediately after the attack. It is safer to let the 'hot' eye settle for a few weeks before removing the cataract (iridotomies will be needed as above).
  • expect a floppy iris, unstable capsule, high vitreous pressure,
  • fibrinous uveitis
  • 20 % cmo (cystoid macular oedema)
  • use
    • a ring
    • AC maintainer (AC=anterior chamber)
  • All biometry, hoffer q but use all others, some times wrong
  • include a goniolysis if there are pas to open angle,
  • Sometimes IOP still high after operation due to pas
  • Eyes very small borderline nanophthalmos, AC shallow, may get aqueous misdirection


Why do some people get an attack of acute glaucoma?

People with glaucoma generally have smaller eyes than normal (21mm long of less instead of the normal 22.4 mm). Taiwanese/Inuits/Chinese seem to have a different anterior chamber structure, and the lens may be further forward than usual. Taiwanese/Inuits/Chinese  are much more prone to angle closure glaucoma than Caucasians. Genes influence the development, and these seem to influence he shape of the eye: generally the angle closure eye is shorter or has a structurally narrow anterior chamber Eye 15. Other genes seem to affect the iris muscle (excess muscle relaxation IOVS 99).


small eyes...mnore acute glaucoma

normal size eye   

smaller eye with narrower anterior chamber enlarge




This is a new treatment for severe epilepsy and migraine. Unfortunately it may cause angle closure glaucoma, see. Treatment is DIFFERENT FROM  ordinary ACUTE GLAUCOMA see


For Professionals

See this page .

Local optometrists with expertise in glaucoma

local optometrists