A 63-year-old woman comes to the emergency department due to a severe, right-sided headache that started 2 hours ago. The pain is centered around the right eye and is associated with nausea and vomiting. She is also seeing halos around lights. The patient has never had a headache like this before. Medical history is notable for hypertension and urinary incontinence. Her medications include valsartan and tolterodine, and she has also been taking trimethoprim-sulfamethoxazole for the last 2 days for a urinary tract infection. Family history is notable for migraine headaches in her mother. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination shows a red right eye with a nonreactive, dilated pupil. Excessive lacrimation is present. Visual acuity is decreased. Laboratory results show an erythrocyte sedimentation rate of 35 mm/h. Which of the following is the most likely diagnosis?
Angle-closure glaucoma | |
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This patient has acute angle-closure glaucoma (ACG), presenting with headache, eye pain, nausea, and decreased visual acuity. ACG is characterized by narrowing of the anterior chamber angle leading to decreased aqueous outflow and elevated intraocular pressure (IOP). The incidence is higher in women (especially age >40), Asian and Inuit populations, and individuals with farsightedness.
In patients predisposed to ACG, the lens is located more forward against the iris, which impairs the normal flow of aqueous humor through the pupil into the anterior chamber, thereby increasing IOP. Sudden angle closure can then occur due to pupillary dilation from anticholinergic medications (eg, tolterodine), sympathomimetics, or low ambient light. Sulfonamides (eg, trimethoprim-sulfamethoxazole) can occasionally trigger ACG due to swelling of structures (eg, lens, retina, choroid) in the posterior chamber.
Examination findings in ACG include conjunctival injection, corneal edema, palpable firmness of the eyeball, and a fixed, mid-dilated pupil. The diagnosis is confirmed by gonioscopy to visualize the corneal angle and/or tonometry to measure IOP.
(Choice B) Cluster headache can cause acute periorbital pain, conjunctival injection, and lacrimation. However, it is more common in young men and typically causes short-lived (minutes), recurrent attacks associated with autonomic symptoms (eg, miosis, lacrimation). Nausea/vomiting and a fixed, mid-dilated pupil are unexpected.
(Choice C) Migraine can cause headache, nausea, and visual disturbances. However, it usually presents in adolescence or early adulthood, and this patient's red eye and nonreactive pupil are more consistent with ACG.
(Choice D) Optic neuritis causes ocular pain, acute vision loss, and an afferent pupillary defect. It is often seen as a manifestation of multiple sclerosis. Optic neuritis most commonly occurs in women age <50 and is not typically associated with nausea/vomiting.
(Choice E) Subarachnoid hemorrhage presents with a severe headache, mental status changes, and neurologic deficits. It does not commonly cause vision loss or a red eye.
(Choice F) Giant cell (temporal) arteritis (GCA) presents in patients age ≥50 with unilateral headache and can cause decreased visual acuity due to anterior ischemic optic neuropathy. However, vomiting and conjunctival erythema are not typical. Although an elevated erythrocyte sedimentation rate (ESR) is sensitive for GCA, this test can be elevated in numerous other conditions (eg, urinary tract infection), and older patients commonly have values above reported laboratory reference ranges (age-corrected normal ESR = [age + 10] ÷ 2).
Educational objective:
Angle-closure glaucoma is characterized by narrowing of the anterior chamber angle leading to decreased aqueous outflow and elevated intraocular pressure. It presents with headache, eye pain, nausea, and decreased visual acuity. Examination findings include conjunctival injection, corneal edema, palpable firmness of the eyeball, and a fixed, mid-dilated pupil. The diagnosis is confirmed by gonioscopy and/or tonometry.