Bilateral simultaneous acute angle closure glaucoma following anticholinergic therapy for vestibular neuritis

Attacks of bilateral simultaneous acute angle closure glaucoma are rare. A 59-year-old man developed vertigo and vomiting, with nystagmus in primary gaze, left-beating nystagmus in left gaze and a positive head impulse test. He was diagnosed with acute vestibular neuritis and received standard therapy, using four drugs that have anticholinergic effects. He subsequently developed bilaterally red eyes, initially diagnosed as bacterial conjunctivitis, and then blurred vision with ocular pain. An ophthalmological assessment identified mid-dilated, non-reactive pupils with corneal oedema and markedly elevated intraocular pressures, consistent with bilateral acute angle closure glaucoma. This was treated with topical and oral ocular hypotensive therapy, pupillary constriction and corneal indentation. Following peripheral iridotomies with the Yttrium Aluminum Garnet laser, his acute angle closure glaucoma rapidly and totally resolved. The use of multiple medications with anticholinergic effects in people with acute vestibular neuritis, and especially in those with a shallow anterior chamber, may cause acute angle closure glaucoma, requiring urgent ophthalmological assessment.