Symptoms

The subacute attack. Here, it might be helpful to consider a typical patient, who might be a male or female, aged about 50 years. Such a patient would have a moderate degree of hyper-metropia and rather a narrow gap between iris and cornea, as shown by the shallow anterior chamber. During the autumn months, this patient's pupil might be noted to be slightly wider, as one might expect with the dimmer illumination, and one evening the pupil dilates sufficiently to allow the iris root to nudge across the angle and obstruct the flow of aqueous. Immediately, the intraocular pressure rises acutely, perhaps to 30 mmHg or 40 mmHg and pain is felt over the eye. At the same time, the acute rise of pressure causes the cornea to become oedematous. Because it is evening, the patient observes that streetlights when viewed through the oedematous cornea appear to have coloured rings around them, as if they were being viewed through frosted glass. At this point, the patient retires to bed and on sleeping the pupil becomes small and the intraocular pressure rise is relieved. After several of these attacks, the patient might seek attention from the family doctor. Patients present as healthy people with evening headaches associated with blurring of the vision and they are wearing moderately thick convex lenses in their spectacles. Subacute glaucoma is easily missed, partly because it is rare among the large number of sufferers from headache. If attention is not sought at this stage or if the diagnosis is missed, one evening the acute attack develops.

The acute attack. After a number of subacute attacks, an irreversible turn of events can occur. The iris root becomes congested, raising the intraocular pressure further and producing further congestion. The headache becomes much worse and the vision becomes seriously impaired. The doctor, who might be called in the following morning, is confronted with a patient who is nauseated and vomiting and at first sight, an acute abdominal problem might be suspected, until the painful red eye should make the diagnosis obvious. Sometimes acute glaucoma does not cause much pain or nausea and in these cases, the physical signs in the eye become especially important (Figure 12.6).

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