Intermittent Angle Closure Diagnosis and Management

Clinical Presentation

The combination of bilateral presentation, transient nature, opaque (blurred) vision, and halos around lights is pathognomonic for intermittent angle closure episodes, according to the American Academy of Ophthalmology 1, 2
Halos around lights are caused by pressure-induced corneal edema, which occurs when intraocular pressure (IOP) rises during angle closure episodes, as reported by the American Academy of Ophthalmology 3, 4
The bilateral nature strongly suggests primary angle closure disease rather than secondary causes, which tend to be unilateral, as stated by the American Academy of Ophthalmology 5
The transient, self-resolving quality indicates intermittent pupillary block that breaks spontaneously before permanent damage occurs, according to the American Academy of Ophthalmology 1, 2
Eye pain or headache during episodes, eye redness, nausea or vomiting, and timing of symptoms are all important factors to consider in the diagnosis of intermittent angle closure, as reported by the American Academy of Ophthalmology 1, 2, 3

Female gender, Asian or Inuit ethnicity, age over 50 years, and family history of angle-closure glaucoma are all demographic risk factors for intermittent angle closure, as stated by the American Academy of Ophthalmology 3
Hyperopia, shallow anterior chamber depth, short axial length, thick and anteriorly positioned crystalline lens, and steep corneal curvature are all ocular anatomic features that increase the risk of intermittent angle closure, according to the American Academy of Ophthalmology 1, 2, 3

Gonioscopy to assess iridocorneal angle and detect iridotrabecular contact (ITC) is an immediate assessment required for the diagnosis of intermittent angle closure, as reported by the American Academy of Ophthalmology 1, 2, 5
IOP measurement, pupil examination, slit-lamp assessment of anterior chamber depth, and refractive status assessment are all important components of the critical examination, according to the American Academy of Ophthalmology 1, 2

Untreated fellow phakic eyes have approximately 50% risk of developing acute angle-closure crisis within 5 years, as stated by the American Academy of Ophthalmology 6, 3
Acute angle-closure crisis can cause rapid glaucomatous optic neuropathy, and 18% of eyes become blind and 48% develop glaucomatous optic neuropathy within 4-10 years following untreated acute angle-closure crisis, according to the American Academy of Ophthalmology 1, 3

Laser peripheral iridotomy (LPI) is the definitive treatment for intermittent angle closure, once the diagnosis is confirmed by gonioscopy showing ITC, as reported by the American Academy of Ophthalmology 6, 3
LPI relieves pupillary block and prevents progression to acute crisis, and both eyes require treatment given the bilateral nature of primary angle closure disease, according to the American Academy of Ophthalmology 6, 3

Do not dismiss transient symptoms as benign, even if the patient is asymptomatic at presentation, as these represent warning episodes before potentially blinding acute attacks, as stated by the American Academy of Ophthalmology 1, 2
Do not delay fellow eye prophylaxis after treating one eye, as acute attacks can occur within days, according to the American Academy of Ophthalmology 6
Avoid pupil dilation until after iridotomy is performed in patients with suspected occludable angles, as dilation can precipitate acute angle-closure crisis, as reported by the American Academy of Ophthalmology 5