Acute Angle-Closure Glaucoma: The Daily PANCE Blueprint
A 67-year-old woman presents with 4 hours of sudden, severe pain in her right eye and blurred vision after watching a movie in a dark theater. She sees halos around lights and is nauseated and vomiting. On exam the right eye is red, the cornea appears hazy ("steamy"), the pupil is mid-dilated and minimally reactive, and the globe feels firm to palpation. Which of the following is the most likely diagnosis?
A. Acute angle-closure glaucoma
B. Anterior uveitis (iritis)
C. Bacterial conjunctivitis
D. Corneal abrasion
E. Optic neuritis
Answer and topic summary
The answer is A. Acute angle-closure glaucoma.
The combination of acute severe eye pain, blurred vision with halos around lights, a red eye with a hazy/steamy cornea, a mid-dilated and poorly reactive (fixed) pupil, a rock-hard globe (elevated intraocular pressure), and nausea/vomiting is the classic picture of acute angle-closure glaucoma — an ophthalmologic emergency often precipitated by dim light or pupillary dilation. Anterior uveitis causes pain and photophobia but with a SMALL, constricted pupil and normal pressure. Bacterial conjunctivitis causes discharge with a normal pupil, normal vision, and no elevated pressure. Corneal abrasion causes a foreign-body sensation with a normal pupil. Optic neuritis causes painful vision loss with an afferent pupillary defect but a normal-appearing, soft eye.
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