Bilateral simultaneous primary acute angle-closure glaucoma

Dear Editor, Acute primary angle-closure glaucoma (PACG) is an important cause of blindness in East Asia.1 It is estimated that the overall prevalence of PACG will increase from 1.44% to 2.01% from 2020 to 2050.2 Acute PACG is typically related to increased high intraocular pressure (IOP), with symptoms including red eye, blurred vision, nausea, vomiting, and headache. Delay in timely IOPlowering treatment can result in permanent optic nerve damage and vision loss.3 Axial hyperopia is the main ocular risk factor for development of primary closure of the anterior chamber angle, while its systemic risk factors include older age, east Asian ethnic origin, and female sex.4 Although generally deemed to be a bilateral condition, PACG often occurs unilaterally, and bilateral simultaneous onset is very rare. For patients with unilateral onset, even if the effect of treatment is not satisfactory, relatively good outcomes can be achieved by carrying out early intervention on the fellow eye. However, for bilateral cases, the condition is usually severe and often comes with a poor prognosis. Therefore, appropriate preventive measures are critical. Here, we present a case of bilateral simultaneous acute PACG related to hyperopia. A 58-year-old Chinese woman presented with intermittent headaches, nausea, vomiting, and acute pain in both eyes for 1 month, which had worsened recently. The patient reported no history of taking anticholinergic and sympathomimetic drugs, nor was any other cause identified. The vital signs included a body temperature of 37.4◦C, blood pressure 150/96 mmHg, and a pulse 90 beats/min. Visual acuities were CF in 50 cm in both eyes and IOP was 51 and 53 mmHg in the right and left eye, respectively. Slit lamp examination revealed conjunctiva hyperemia, corneal edema, mid-dilated pupils, and shallow anterior chambers peripherally and centrally (Fig. 1). Fundus examination had a hazy view. B-scan ultrasonography demonstrated that retinas were attached in both eyes. Initial treatments included systemic acetazolamide 250 mg twice a day, pilocarpine 2% four times a day, brinzolamide 1.0% twice-a-day, and fixed-combination eye drops containing timolol maleate 0.5% and brimonidine tartrate 0.2% twice-a-day. A few hours later, the IOPs reduced to 28 OD and 32 OS mmHg respectively. The patient underwent a laser peripheral iridotomy and was sent home with prednisolone acetate eye drops to be applied four times a day, acetazolamide 500 mg every