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Acute Angle-Closure Glaucoma in

Emergency Medicine Treatment &
Management
Updated: Apr 13, 2017
Author: Joseph Freedman, MD; Chief Editor: Steven C Dronen, MD, FAAEM more...

TREATMENT

Prehospital Care
The patient should be brought to the hospital in an expeditious manner to have intraocular
pressure (IOP) reduced. The patient should remain in the supine position as long as
possible. The urge to wear eye patches, covers, or blindfolds should be resisted. By
maintaining the conditions that cause pupillary dilation, these articles help perpetuate the
attack. Their potential negative effects outweigh any presumed benefit.

Emergency Department Care

The treatment of acute angle-closure glaucoma (AACG) consists of IOP reduction,
suppression of inflammation, and the reversal of angle closure. Once diagnosed, the initial
intervention includes acetazolamide, a topical beta-blocker, and a topical steroid.

Acetazolamide should be given as a stat dose of 500 mg IV followed by 500 mg PO. A

dose of a topical beta-blocker (ie, carteolol, timolol) will also aid in lowering IOP. Studies
have not conclusively demonstrated the superior neuronal or visual field protectiveness of
one beta-blocker over another. Both beta-blockers and acetazolamide are thought to
decrease aqueous humor production and to enhance opening of the angle. An alpha-
agonist can be added for a further decrease in IOP.

Inflammation is an important part of the pathophysiology and presenting symptomology.

Topical steroids decrease the inflammatory reaction and reduce optic nerve damage. The
current recommendation is for 1-2 doses of topical steroids.

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 Addressing the extraocular manifestations of the disease is critical. This includes
analgesics for pain and antiemetics for nausea and vomiting, which can drastically
increase IOP beyond its already elevated level. Placing the patient in the supine position
may aid in comfort and reduce IOP. It is also believed that, while supine, the lens falls
away from the iris decreasing pupillary block.

After the initial intervention, the patient should be reassessed. Reassessment includes
evaluating IOP, evaluating adjunct drops, and considering the need for further
intervention, such as osmotic agents and immediate iridotomy.

Approximately 1 hour after beginning treatment, pilocarpine, a miotic that leads to opening
of the angle, should be administered every 15 minutes for 2 doses. In the initial attack, the
elevated pressure in the anterior chamber causes a pressure-induced ischemic paralysis
of the iris. At this time, pilocarpine would be ineffective. During the second evaluation, the
initial agents have decreased the elevated IOP and hopefully have reduced the ischemic
paralysis so pilocarpine becomes beneficial in relieving pupillary block.

Pilocarpine must be used with caution. Theoretical concerns exist about its mechanism of
action. By constricting the ciliary muscle, it has been shown to increase the axial
thickness of the lens and to induce anterior lens movement. This could result in reducing
the depth of the anterior chamber and worsening the clinical situation in a paradoxical
reaction. Despite this, pilocarpine is recommended to be used as an additional agent. [17]

No standard rate of reduction for IOP exists; however, Choong et el identified a

satisfactory reduction as IOP less than 35 mm Hg or a reduction greater than 25% of
presenting IOP. [16] If the IOP is not reduced 30 minutes after the second dose of
pilocarpine, an osmotic agent must be considered. An oral agent like glycerol can be
administered in nondiabetics. In diabetics, oral isosorbide is used to avoid the risk of
hyperglycemia associated with glycerol. Patients who are unable to tolerate oral intake or
do not experience a decrease in IOP despite oral therapy are candidates for IV mannitol.

Hyperosmotic agents are useful for several reasons. They reduce vitreous volume, which,
in turn, decreases IOP. The decreased IOP reverses iris ischemia and improves its
responsiveness to pilocarpine and other drugs. Osmotic agents cause an osmotic diuresis
and total body fluid reduction. They should be administered with caution in cardiovascular
and renal patients. Choong et el demonstrated that 44% of patients required the addition
of an osmotic agent to decrease IOP. [18] Repeat doses may be necessary if no effect is
seen and if tolerated by the patient.

When medical therapy proves to be ineffective, corneal indentation (CI) can be used as a
temporizing measure to reduce IOP until definitive treatment is available. As the cornea is
indented, aqueous humor is displaced to the periphery of the anterior chamber, which
serves to temporarily open the angle. This leads to immediate reduction of IOP and
occasionally may completely abort the attack. After applying topical anesthetic, any
smooth instrument can be used to perform this procedure, including a gonioprism (ideal, if

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 available), or a cotton-tipped applicator. Obviously, a concern with performing CI is the
possibility for damage to the corneal epithelium, which may complicate the patient’s
course. [19]

Laser peripheral iridotomy (LPI), performed 24-48 hours after IOP is controlled, is
considered the definitive treatment for AACG. Furthermore, LPI may be offered
prophylactically to individuals anatomically predisposed to AACG if identified before the
first acute attack. While LPI is the current definitive treatment, evidence suggests that
argon laser peripheral iridoplasty (ALPI) and anterior chamber paracentesis (ACP) may
have increasing roles in the management of AACG.

In ALPI, burns are made in the peripheral iris resulting in iris contraction and opening of
the angle. Some studies suggest ALPI causes a more immediate decrease in IOP,
resulting in better outcomes with fewer side effects than systemic therapy. [20] However, a
recent randomized-controlled trial comparing LPI plus ALPI compared with ALI alone
failed to show improved outcomes with ALPI as an adjunctive therapy. [21] Systemic
therapy must still be used with ACP, but ACP appears to instantaneously relieve
symptoms.

An additional alternative is lens extraction. Although its role in AACG has not been
completely established, it has been proven to effectively reduce IOP without the need for
medication postoperatively. Furthermore, it offers a therapeutic advantage for individuals
with coexisting cataracts. [22]

The choice of which therapy to use will be made by an ophthalmologist who will evaluate
all patients via gonioscopy with complete inspection of the angle. At institutions where
ophthalmologic consultation is immediately available, initial treatment should be
performed in conjunction with the specialist.

If ophthalmologic consultation is not immediately available, the emergency department

physician must begin pharmacologic therapy as described above. After appropriate
therapy aimed at IOP reduction, ophthalmologic evaluation must be ensured by
transferring the patient, if necessary. If the IOP is unchanged or increased, with
appropriate pharmacologic therapy, the attack most likely will terminate only with LPI.
Because outcome is adversely affected by the duration of symptoms, expeditious
evaluation by a specialist is required. Ocular massage through a closed eyelid may be
performed while waiting for ophthalmology if no other treatment reduces IOP.

Consultations
Ophthalmologic consultation should be obtained as soon as possible because acute-
angle closure glaucoma is an ophthalmic emergency.

Medication

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