Acute angle-closure glaucoma is an ocular emergency. If left untreated, it may lead to blindness.

1. Call ophthalmology for emergent consultation. They may wish to dictate medical treatment before further procedures/surgery.
2. Treat patient with the following:
   1. Timolol 0.5% 1 drop q15min for 2-3 doses in affected eye only.
   2. Brimonidine 0.1-0.2% 1 drop or apraclonidine 0.5% 1 drop q15min for 2-3 doses in affected eye only.
   3. Pilocarpine 2% 1 drop to affected eye.
   4. Acetazolamide 500mg PO/IM/IV then 250mg PO/IM/IV q6h.
   5. Mannitol 0.5-2g/kg IV over 20 minutes if no response to other medications.
3. Measure IOP every 60 minutes.

Acute angle-closure glaucoma (symptomatic) is a clinical condition that occurs in <30% of patients with closed-angle glaucoma (asymptomatic).

Acute angle-closure glaucoma is symptomatic and characterized by conjunctival hyperemia, corneal edema, a shallow anterior chamber, and very high intraocular pressures (typically >30mmHg).

Symptoms of acute angle-closure glaucoma include ocular pain, nausea/vomiting, and vision changes (most notably blurring with light halos).

It is an ocular emergency that with delayed treatment (even several hours) can cause chronic glaucoma, permanent retinal vascular occlusions, optic atrophy, and permanent blindness.

Risk factors include female sex, older age, Asian ethnicity.

Diagnosis is based on tonometry demonstrating elevated intraocular pressure.

The presumptive diagnosis can be made for an IOP >30mmHg (other sources suggest 21mmHg). There is rarely acute vision loss and pain with pressures <50mmHg.

No role for imaging.

Clinical Features:

1. Painful, red eye
2. Blurring of vision
3. Headache
4. Nausea and vomiting

On Examination:

1. Hazy cornea due to high IOP
2. Mid-dilated, poorly/non-reactive pupil
3. Dull corneal reflex
4. Shallow anterior chamber
5. Increased IOP of >30mmHg (normal 6-22mmHg)
6. Reduced visual acuity

Patient should be treated in the emergency department with topical and systemic medications to temporize damage to the optic nerve.

Ophthalmology should then be involved for definitive management in the form of iridotomy.

Medication Classes

1. Prostaglandin Analogues (e.g. latanoprost)
2. Beta-blockers (e.g. timolol)
3. Alpha-agonists (e.g. brimonidine, apraclonidine)
4. Carbonic anhydrase inhibitors (e.g. acetazolamide, dorzolamide)
5. Cholinergic agonists (e.g. pilocarpine)

Medical Management

1. Timolol 0.5% 1 drop q15min for 2-3 doses in affected eye only
2. Brimonidine 0.1-0.2% 1 drop or apraclonidine 0.5% 1 drop q15min for 2-3 doses in affected eye only
3. Pilocarpine 2% 1 drop to affected eye
4. Acetazolamide 500mg PO/IM/IV then 250mg PO/IM/IV q6h
5. Mannitol 0.5-2g/kg IV over 20 minutes if no response to other medications

Ultimately, patients require referral to ophthalmology for laser peripheral iridotomy, a procedure which creates a whole in the iris to allow drainage of aqueous humor.

Dictated by ophthalmology. Patients whose intraocular pressure is not responsive to medical management will require emergent iridotomy or surgery.

Patients with acute angle-closure glaucoma require emergent ophthalmology consultation. This may require transport depending on your centre.

All patients with acute angle-closure glaucoma require urgent consultation by ophthalmology.

Patients will require definitive management by ophthalmology within 24 hours. Disposition should be determined by the consulting ophthalmologist.

1. Petsas A, Chapman G, Stewart R. Acute angle closure glaucoma – A potential blind spot in critical care. J Intensive Care Soc. 2017;18(3): 244-246. 10.1177/1751143717701946

   
   

2. Ah-kee, EY, Egong E, Shafi A, Lim LT, Yim JL.  A review of drug-induced acute angle closure glaucoma for non-ophthalmologists. Qatar Med J. 2015. 2015(6): 1-8. 10.5339/qmj.2015.6

   
   

3. Weinreb RN, Aung T, Medeiros FA.  The Pathophysiology and Treatment of Glaucoma: A Review. JAMA. 2014;311(18):1901-1911. doi:10.1001/jama.2014.3192

   
   

4. Hammond VM, Mattu A, Swadron S. Acute Glaucoma. EM RAP. October 14, 2022.  Accessed December 8, 2022.  https://www.emrap.org/corependium/chapter/recQnDsM14OI8Vjzy/Acute-Glaucoma#h.5xi7ezvh1v7o

   
   

5. Shields SR. Managing eye disease in primary care. Postgrad Med. 2000; 108(5): 99-106. 10.3810/pgm.2000.10.1781