Acute angle closure (which may lead to glaucoma) Questionnaire/history: Acute eye pain, often severe, and associated with headache, nausea, and vomiting caused by the pain? Red eye? Impaired visual acuity and lights are seen surrounded by halos — caused by a hazy oedematous cornea? Risk factors and/or a history of previous episodes of blurred vision, headaches or eye pain associated with nausea and seeing halos around lights, typically occurring in the evening and relieved by sleeping? Precipitating factor such as watching television in a darkened room, adopting a semi-prone position (for example, reading), use of an adrenergic drug (for example phenylephrine), or use of an antimuscarinic drug (for example a tricyclic antidepressant)? Past medical history? Current medication? Drug allergies? Examination: Semi-dilated and fixed pupil (classically, the pupil becomes fixed in a vertically oval shape)? Tender, hard eye (palpate very gently)? Very high IOP? Management: Admit immediately for specialist ophthalmology assessment and treatment If immediate admission is not possible, start emergency treatment in primary care: Let the person lie flat with their face up and head not supported by pillows, as this may relieve some of the pressure on the angle If the drugs are available, give: pilocarpine eye drops, one drop of 2% in blue eyes or 4% in brown eyes; acetazolamide 500 mg orally to reduce production of aqueous humour (provided that there are no contraindications), analgesia and an anti-emetic, if required Sub-acute (intermittent) angle closure Similar symptoms to acute angle closure but may be less severe and often soon resolve, typically on lying supine and closing the eyes, or after sleeping? Referred to an ophthalmologist? Chronic primary angle closure glaucoma (PACG) Visual field defects affect vision? Cupped optic disc? Increased IOP? Referred to an ophthalmologist? Reference(s): NICE CKS: Glaucoma