Acute Attack of Glaucoma

Acute attack of glaucoma is the greatest degree of disorders of the IOP regulation in closed-angle glaucoma. Acute attack rises usually in the second half of the day or in the evening after emo­tional tension, taking of great amount of fluid.

Clinical course. The visual acuity lowers up to 0.09-0.01, some­times to a photoperception. There is strong pain in the eye and in the corresponding half of the head with an irradiation to the trigeminal nerve and remote organs: in heart, epigastric area, stom­ach. Nausea, vomiting are typical.

Objective signs are: lacrimation, the corneal syndrome, oede­ma of the lids; stagnant injection of vessels of a front department of the eye ("the head of Medusa"); oedema of the cornea, lowe­ring of its sensitivity, the surface of the cornea is rough, as if pricked by a needle; a narrow anterior chamber; a wide pupil (midriasis) with weak or no reaction to light; greenish colour of the eye fun­dus reflex; if the eye fundus is visible, the atrophy of the optic nerve, pulsing of central artery of the retina are defined; IOP is 60-80 mm Hg; the eye is hard, as a stone (T+3).

Outcomes may be as follows:

• fast decrease of IOP leads to visual functions recovery, but the pupil usually remains wide;

• terminal (absolute) painful glaucoma develops with the strong steady pain in the eye, stagnant injection ("the head of Medusa"), bullous (vesicles) keratopathy, rubeosis of the iris. Vi­sual acuity is 0;

• secretion of aqueous humour and IOP reduces, all clinical signs disappear gradually, but the vision, as a rule, never returns;

• acute attack of glaucoma may recur.

Differential diagnosis of the acute attack of glaucoma should be carried out with: acute gastrointestinal diseases, poisonings; hypertonic crisis; attack of stenocardia, if the attack of glaucoma is on the left eye; acute iridocyclitis (Table 3).

First aid in acute attack of glaucoma. 1-2% pilocarpin solution is instilled every 15-20 minutes; per os diacarb 0,5 (fonurit 0.25 or hypothiazid 25-100 mg) is given. A patient must immediately be refered to ophthalmological clinic.

Specialized help in acute attack of glaucoma. In ophthalmolog­ic clinic 1% or 2% pilocarpin solution is instilled every 15 minutes during 2 hours and then every hour. 25 mg of aminacin or lytic mixture (1 ml of 2.5% aminacin + 1 ml of 1% dimedrol or 1.0 ml of 2.5% pipolphen + 1.0 ml of 2% promedol) is entered intravenous­ly. Diacarb is administered orally in the dose of 0.25-0.5 g 2 times a day. The hyperosmotic agents are used (urea, glycerol, manni-tol, salt laxative). Diverted procedures (hot baths for legs, leech on temples, mustard plasters on a nape) are used too. The antiglau-comatic operation (iridectomy) is necessary, when medical thera­py has failed within 24 hours. If IOP decreases after medical the­rapy, it is recommended planned antiglaucomatic operation in a period of IOP normalization.

Table 3. Differential diagnosis of the acute attack of glaucoma and iridocyclitis

Symptoms	Acute attack of glaucoma	Iridocyclitis
Iridescent circles	present	absent
Irradiation of a pain	present	absent
Injection of the eye	stagnant	pericorneal
The cornea The anterior chamber	oedematous, loss of sensitivity and transparency shallow	transparent, mirror, sensitive middle
Pupil	wide	narrow
IOP	very high	normal or hypotonia