Snapshot A 55-year-old male presents with severe light-sided pain around the eye. He experiences blurred vision and nausea. His symptoms began while at the movie theatre. On physical exam, decreased visual acuity is appreciated. Inspection of the eye is shown. Introduction Optic neuropathy characterized by optic nerve damage and visual abnormalities majority of patients have increased intraocular pressure (IOP) important causative risk factor associated with increased resistance to aqueous outflow compresses retinal blood supply or retinal ganglion cells optic disc atrophy with cupping → visual loss Aqueous humor inflow and outflow maintains intraocular pressure ciliary body produces aqueous humor humor gets resorbed by the trabecular meshwork and uveoscleral outflow pathway Glaucoma can be characterized into open-angle or angle-closure Epidemiology second leading cause of blindness cataracts is first open-angle glaucoma is more common risk factor examples family history age race Open-Angle Glaucoma Open-angle glaucoma is most common among Europeans and African Americans Presentation usually asymptomatic Etiology primary open-angle glaucoma unclear secondary open-angle glaucoma neovascularization e.g., diabetes mellitus debri e.g., RBCs, WBCs, pseudoexfoliation corticosteroids retinal detachment Evaluation visual acuity visual field testing intraocular pressure pachymetry Treatment pharmacologic increases aqueous outflow prostaglandins (becoming first-line) α-agonists cholinomimetics decreases aqueous production carbonic anhydrase inhibitors α-agonists β-blockers laser therapy trabeculoplasty surgical filtration bleb Prognosis, prevention, and complications prognosis does not substantially reverse prevention may involve lower IOP complications blindness Angle-Closure Glaucoma Angle-closure glaucoma is more common in people of Asian decent Presentation symptoms very painful frontal headache ↓ vision (photophobia/blurry vision) halos around lights eye very firm physical symptoms fixed-dilated pupil corneal clouding conjunctival injection Etiology obstruction of flow between the iris and cornea can have primary (anatomy) or secondary (pulling or pushing the iris to shorten the angle) causes angle-closure crisis is an ophthalmic emergency can be caused by mydriatic agents such as atropine (pupil dilation reduces aqueous humor outflow), infection, or lens dislocation Evaluation visual acuity visual field testing intraocular pressure evaluation of anterior chamber via slit-lamp gonioscopy (gold standard) Treatment iridotomy topical β-blockers, α2-agonists epinephrine contraindicated! α1-agonism causes mydriasis oral carboanhydrase inhibitors Prognosis, prevention, and complications prognosis progressive vision loss that may lead to blindness if not detected early and not properly managed