Acute Angle Closure Glaucoma – Diagnosis and Treatment
First 5 Minutes
Acute angle-closure glaucoma is an ocular emergency. If left untreated, it may lead to blindness.
- Call ophthalmology for emergent consultation. They may wish to dictate medical treatment before further procedures/surgery.
- Treat patient with the following:
- Timolol 0.5% 1 drop q15min for 2-3 doses in affected eye only.
- Brimonidine 0.1-0.2% 1 drop or apraclonidine 0.5% 1 drop q15min for 2-3 doses in affected eye only.
- Pilocarpine 2% 1 drop to affected eye.
- Acetazolamide 500mg PO/IM/IV then 250mg PO/IM/IV q6h.
- Mannitol 0.5-2g/kg IV over 20 minutes if no response to other medications.
- 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.
- Painful, red eye
- Blurring of vision
- Nausea and vomiting
- Hazy cornea due to high IOP
- Mid-dilated, poorly/non-reactive pupil
- Dull corneal reflex
- Shallow anterior chamber
- Increased IOP of >30mmHg (normal 6-22mmHg)
- 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.
- Prostaglandin Analogues (e.g. latanoprost)
- Beta-blockers (e.g. timolol)
- Alpha-agonists (e.g. brimonidine, apraclonidine)
- Carbonic anhydrase inhibitors (e.g. acetazolamide, dorzolamide)
- Cholinergic agonists (e.g. pilocarpine)
- Timolol 0.5% 1 drop q15min for 2-3 doses in affected eye only
- Brimonidine 0.1-0.2% 1 drop or apraclonidine 0.5% 1 drop q15min for 2-3 doses in affected eye only
- Pilocarpine 2% 1 drop to affected eye
- Acetazolamide 500mg PO/IM/IV then 250mg PO/IM/IV q6h
- 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.
Criteria For Hospital Admission
Dictated by ophthalmology. Patients whose intraocular pressure is not responsive to medical management will require emergent iridotomy or surgery.
Criteria For Transfer To Another Facility
Patients with acute angle-closure glaucoma require emergent ophthalmology consultation. This may require transport depending on your centre.
Criteria For Close Observation And/or Consult
All patients with acute angle-closure glaucoma require urgent consultation by ophthalmology.
Criteria For Safe Discharge Home
Patients will require definitive management by ophthalmology within 24 hours. Disposition should be determined by the consulting ophthalmologist.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Clinical Features and Background Information
This information is based on a systematic review of 210 articles between Jan 2000 and Sept 2013. Results were published in JAMA.
Treatment of Acute Angle Closure Glaucoma
Current treatment of this condition is based primarily on clinician experience and expert opinion. There are no large trials available that compare topical or systemic treatment options.
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
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
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
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
Shields SR. Managing eye disease in primary care. Postgrad Med. 2000; 108(5): 99-106. 10.3810/pgm.2000.10.1781
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 27, 2022
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