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Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 16

Acute angle closure glaucoma in a patient admitted at the intensive care unit for the management of COVID-19

Department of Ophthalmology, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Tecnológico de Monterrey, Monterrey, México

Date of Submission24-Apr-2021
Date of Decision25-Apr-2021
Date of Acceptance27-Apr-2021
Date of Web Publication18-May-2021

Correspondence Address:
Dr. Patricio J Rodriguez-Valdes
Instituto de Oftalmologia y Ciencias Visuales Centro Medico Zambrano Hellion, Av. Batallon de San Patricio No. 112, Col. Real de San Agustin, N.L, CP 66278
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_90_21

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Drug-induced acute angle closure glaucoma (AACG) is a blinding condition that requires urgent management. Unfavorable conditions encountered at the intensive care unit (ICU) represent an increased risk of developing AACG. A 60-year-old female complained of photophobia, pain, and vision loss in her right eye while hospitalized in the ICU for COVID-19 management. Symptoms developed after the use of nebulized ipratropium bromide and salbutamol, prone positioning, and darkroom conditions. The patient was discharged 3 weeks after and diagnosed with AACG the next day. Despite management with hypotensive eye drops and cataract surgery, the patient developed bilateral glaucomatous damage and vision loss in her right eye.

Keywords: Cataract extraction, COVID-19 pandemic, drug-induced acute angle closure glaucoma, intensive care unit, intraocular pressure

How to cite this article:
Ruiz Lozano RE, Galvan-Lopez CA, Garza-Garza LA, Rodriguez-Valdes PJ. Acute angle closure glaucoma in a patient admitted at the intensive care unit for the management of COVID-19. Pan Am J Ophthalmol 2021;3:16

How to cite this URL:
Ruiz Lozano RE, Galvan-Lopez CA, Garza-Garza LA, Rodriguez-Valdes PJ. Acute angle closure glaucoma in a patient admitted at the intensive care unit for the management of COVID-19. Pan Am J Ophthalmol [serial online] 2021 [cited 2022 Aug 7];3:16. Available from: https://www.thepajo.org/text.asp?2021/3/1/16/316305

  Introduction Top

The explosive spread of the COVID-19 pandemic has led to high demand and an ongoing strain of intensive care services worldwide. Although most COVID-19 cases are mild, it is estimated that 14% of the cases require hospitalization. Of those, 30% become critically ill and require management at the intensive care unit (ICU).[1] Unfortunately, the lack of medical and nursing staff and the high demand of ICU services amid the current pandemic, result in the need of focusing efforts to immediate life-threatening problems. Because of the latter, other serious issues, including those related to the eye, may be commonly neglected.[2] Patients who require sedation, mechanical ventilation, a prolonged stay in the ICU, and multiple medications are at higher risk of developing serious ocular complications; thus, the ICU is an unsafe environment for the eye.[3]

Drug-induced acute angle closure glaucoma (AACG) is a true ophthalmic emergency that warrants immediate treatment to avoid permanent vision loss.[4],[5] It occurs when there is an obstruction to the aqueous humor drainage at the iridocorneal angle by an anterior displacement of the iris, usually related to pupillary dilation (physiological or pharmacological) leading to sudden increase of intraocular pressure (IOP). Several medications, including cholinergic agonists, anticholinergics, sulfonamides, antidepressants, anticonvulsants, adrenergic agonists, and serotoninergic drugs, among others, have been reported to trigger an acute attack of angle closure in patients with predisposing anatomical changes in the anterior segment of the eye.[6] Many of these medications are commonly prescribed in the ICU setting.

Herein, we report an exemplifying case of a patient who developed drug-induced AACG after receiving treatment for COVID-19 at the ICU. The correct diagnosis and management were delayed for 3 weeks until the patient was discharged and thus, glaucomatous optic nerve damage and permanent vision loss occurred in one of her eyes.

  Case Report Top

A 60-year-old female presented with a 3-week history of bilateral photophobia, vision loss, and frontal pain while hospitalized in the ICU for COVID-19 management. After reviewing her medical record, symptoms began after the use of nebulized ipratropium bromide and salbutamol. She received oral tramadol with mild improvement. She also referred prolonged prone positioning and being at darkroom conditions. Interconsultation with an ophthalmologist was not requested. One day after being discharged, she arrived at our ophthalmology department. Currently, she is under no medications. Snellen best-corrected visual acuity was 20/200 in the right eye and 20/20 in the left eye. Personal or family history of ophthalmic diseases was denied. Slit-lamp examination showed conjunctival hyperemia, moderate corneal edema in her right eye, and bilateral dilated (6-mm diameter) and fixed pupils, a narrow anterior chamber, and Grade 1 nuclear sclerosis in both eyes (according to the Lens Opacities Classification System III grades criteria) [Figure 1]. IOP was of 52 mmHg and 50 mmHg in the right and left eye, respectively. Gonioscopy evaluation revealed a closed right iridocorneal angle and a Grade 0–1/IV (Shaffer classification) left iridocorneal angle. After performing retinoscopy and evaluating her spectacles, we documented an hypermetropic refraction. Fundus evaluation showed optic nerve damage with retinal nerve fiber layer thinning of the right eye and an apparently normal optic nerve in the left eye. We requested an optical coherence tomography of the optic nerve, Humphrey visual fields, as well as ultrasound biomicroscopy. Studies confirmed the diagnosis of AACG due to pupillary block in the right eye and a narrow angle in the left eye [Figure 2]. The patient was initiated, before lens extraction, with oral acetazolamide 250 mg QID and in both eyes, with latanoprost 0.005% eye-drops QD, a fixed combination of dorzolamide hydrochloride 2%/timolol 0.5%/brimonidine tartarate 0.2% eye drops BID, and pilocarpine 2% eye-drops QID. She underwent uncomplicated phacoemulsification in both eyes to relieve the pupillary block and restore normal aqueous humor outflow. Nearly 2 months after surgery, current visual acuity is 20/60 and 20/20 in her right and left eye, respectively. She is currently with a fixed combination of dorzolamide hydrochloride 2%/timolol 0.5% eye drops BID and latanoprost eye drops 0.005% QD in her right eye. No hypotensive medications were required in the left eye. Current IOP is 16 mmHg in both eyes.
Figure 1: Clinical picture of the right eye depicting a mid-dilated, nonreactive pupil secondary to pupillary block. The eye is injected due to high intraocular pressure

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Figure 2: Visual field grayscale images (left column), optical coherence tomography of the optic nerve showing the retinal nerve fiber layer (middle column), and ultrasound biomicroscopy (right column) of the right (a-c) and left (d-f) eye. Visual field image of the right eye (a) shows a marked superior and inferior hemifield defect with macular involvement. Mild damage is observed in the superior hemifield of the left eye (d). An enlarged (red arrowhead) and a normal (black arrowhead) blind spot is observed in the right and left eye, respectively. Retinal nerve fiber layer map of the right eye (b) shows a more marked diffuse thinning (in red) in the superior and nasal quadrants, which corresponds to the area of defect shown at the visual field. Left eye (e) image depicts only mild nasal damage. Ultrasound biomicroscopy image of the right (c) and left (f) eye showing complete pupillary block (red asterisks). The iris showed convexity (white arrows) because of aqueous humor accumulation and the angle is closed (red arrows)

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  Conclusion Top

Well-known risk factors for AACG include short hypermetropic eyes, female gender, older age, Asian ethnicity, and a preexisting narrow angle caused by an enlarged lens in a patient with cataract.[6],[7] Drug-induced AACG is a clinical entity, in which the episode of angle closure occurs, in predisposed eyes, after the use of certain medications. Pupillary block, which occurs when the border of the iris is in contact with the anterior lens surface, is the most common mechanism of angle closure.[6] Immediate referral to an eye specialist usually occurs since AACG causes severe pain, photophobia, red eyes, blurred vision, and nausea and vomiting. Nevertheless, in ICU patients, the diagnosis may often be neglected and thus, treatment delayed. The hindmost since symptoms of AACG may be wrongly attributed to other conditions and/or masked by certain medications.[7],[8] Moreover, the current COVID-19 overwhelming of ICU services may also result in an inadequate approach and management of patients with AACG.

In our patient, several preexisting risk factors were present, including a short length hypermetropic eye, female gender, older age, and an enlarged cataractous lens. In susceptible individuals, drugs that induce pupillary dilation can precipitate AACG.[4] Our patient referred frontal headache centered around her right eye after administration of nebulized ipratropium bromide and salbutamol. Ipratropium bromide is an antimuscarinic drug that causes transient pupillary dilation. When mydriasis occurs, there is an anterior shift of the iris roots toward the angle, which impedes aqueous humor flow from the posterior to the anterior chamber of the eye.[3] This fluid accumulation causes an increased pressure at the posterior chamber, leading to further anterior bowing of the iris, with worsening blockage of aqueous outflow.[9] The latter, results in an increased IOP. Salbutamol, a β2-adrenergic agonist to aid respiratory function, leads to a further rise in IOP by increasing aqueous humor production.[7],[9] The ocular effects of this agents may be attributed to incidental inoculation of the aerosolized drugs in the conjunctival sac.[10] The use of protective eyewear, proper fitting of the face mask, and avoiding simultaneous administration of both drugs has been recommended.[11]

Other mechanisms that may have worsened angle closure and increasing IOP were the darkroom conditions and prone positioning.[12],[13] A recent study by Liu et al. demonstrated that mean anterior chamber depth (ACD) and iris-lens distance (ILD) were significantly less in the dark.[13] Darkroom conditions enhance pupillary dilation, resulting in reduced ACD and ILD with subsequent angle narrowing and crowding of anterior chamber structures. The latter may increase the risk of angle closure. On the other hand, Saran et al. evaluated the effect of prolonged duration of prone positioning on IOP in acute respiratory distress patients.[12] A significant increase in IOP was observed after 10 min of prone positioning. Moreover, such effect lasted up to 30 min after cessation of prone positioning.[12]

In conclusion, AACG is a serious ophthalmic emergency that can result in major morbidity. Unfavorable conditions encountered at the ICU in patients with high risk of developing AACG increase disease occurrence and delayed detection and management. To the best of our knowledge, this is the first case reported, in which medications and environmental conditions inherent of the ICU resulted in AACG development in a COVID-19 patient. As AACG requires prompt diagnosis and management, ICU services must consider including routine eye evaluations assessing for pain, vision loss, photophobia, and red eyes. The latter, to avoid AACG and other potentially blinding conditions in critically ill patients at the ICU.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kleinpell R, Ferraro DM, Maves RC, Kane Gill SL, Branson R, Greenberg S, et al. Coronavirus disease 2019 pandemic measures: Reports from a national survey of 9,120 ICU clinicians. Crit Care Med 2020;48:e846-55.  Back to cited text no. 1
Rosenberg JB, Eisen LA. Eye care in the intensive care unit: Narrative review and meta-analysis. Crit Care Med 2008;36:3151-5.  Back to cited text no. 2
Parekh PH, Boente CS, Boente RD, Meeker JW, Carlos WG. Ophthalmology in critical care. Ann Am Thorac Soc 2019;16:957-66.  Back to cited text no. 3
Marchini G, Chemello F, Berzaghi D, Zampieri A. New findings in the diagnosis and treatment of primary angle-closure glaucoma. Prog Brain Res 2015;221:191-212.  Back to cited text no. 4
Ruiz-Lozano RE, Rodriguez-Garcia A, Garza-Garza LA, Rodriguez-Garcia A. Evaluating glaucoma during the times of Covid-19: Simple measures may save lives! Expert Rev Ophthalmol 2020;15:263-5.  Back to cited text no. 5
Yang MC, Lin KY. Drug-induced Acute Angle-closure Glaucoma: A Review. J Curr Glaucoma Pract 2019;13:104-9.  Back to cited text no. 6
Lotery AJ, Frazer DG. Iatrogenic acute angle closure glaucoma masked by general anaesthesia and intensive care. Ulster Med J 1995;64:178-80.  Back to cited text no. 7
Akal A, Kucuk A, Yalcin F, Yalcin S. Do we really need to panic in all acute vision loss in ICU? Acute angle-closure glaucoma. J Pak Med Assoc 2014;64:960-2.  Back to cited text no. 8
Petsas A, Chapman G, Stewart R. Acute angle closure glaucoma – A potential blind spot in critical care. J Intensive Care Soc 2017;18:244-6.  Back to cited text no. 9
Grixti A, Sadri M, Datta AV. Uncommon ophthalmologic disorders in intensive care unit patients. J Crit Care 2012;27:746.e9-22.  Back to cited text no. 10
Hall SK. Acute angle-closure glaucoma as a complication of combined beta-agonist and ipratropium bromide therapy in the emergency department. Ann Emerg Med 1994;23:884-7.  Back to cited text no. 11
Saran S, Gurjar M, Kanaujia V, Ghosh PS, Gupta A, Mishra P, et al. Effect of prone positioning on intraocular pressure in patients with acute respiratory distress syndrome. Crit Care Med 2019;47:e761-6.  Back to cited text no. 12
Liu X, Zhang Y, Li L, Bian A, Zhou Q. Iris lens distance to predict the risk of intraocular pressure elevation after dark room provocative test. Graefes Arch Clin Exp Ophthalmol 2019;257:2723-8.  Back to cited text no. 13


  [Figure 1], [Figure 2]

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