Acute angle-closure: Treatment

Acute angle-closure glaucoma is an emergency and should be initially managed with IOP-decreasing medications that have a rapid onset of action. Once IOP has decreased, patients should undergo a definitive procedure as soon as possible to prevent recurrence.

• Emergency ophthalmology consultation

• Place the patient in a supine position.

• Ensure the contralateral eye has been evaluated for urgent treatment, even if it is asymptomatic. [11]

• Administer supportive care as needed.

  • Analgesics (see pain management)

  • Antiemetics (e.g., ondansetron)

• Indication: initiate in all patients as soon as a diagnosis of acute angle-closure glaucoma is made. [6][11][13][15]

• Initial pharmacological regimen: There is currently no standardized recommendation for empiric management of acute angle-closure glaucoma. The following regimen may be followed with due consideration of any comorbidities. [6][11][13][15]

  • Topical ophthalmic therapy. Administer the following eye drops in succession, one minute apart: [15]

    • Direct parasympathomimetic: pilocarpine [6][13][15]

    • Alpha-2 agonist: apraclonidine

    • Beta blocker: timolol

  • PLUS a systemic carbonic anhydrase inhibitor [26]

    • Acetazolamide

    • OR methazolamide

  • Consider also the following alternatives:

    • Betaxolol

    • Brinzolamide

    • Dorzolamide

    • Levobunolol

    • Brimonidine

• If IOP is still elevated after 30–60 minutes: The following should be given only under the guidance of an ophthalmologist. [15][25]

  • Repeat eye drops from above up to three times. [15]

  • Consider a systemic hyperosmotic agent if IOP remains high after 60 minutes of initiating therapy. [13][25]

    • In patients with nausea: IV mannitol

    • In patients without significant nausea [25]

      • Nondiabetic patients: oral glycerine

      • Diabetic patients: oral isosorbide

• If IOP is decreasing: Examine for other signs of resolution of the acute attack. [6][13]

  • Symptomatic improvement (decreased pain and nausea; improvement of vision)

  • Clear cornea (resolution of corneal edema)

  • Decreased conjunctival hyperemia

  • Normal pupillary size and reaction

• Anterior chamber paracentesis

  • Indication: Consider for vision-threatening elevation in IOP refractory to medical management. [11][27]

  • Procedure: controlled drainage of some of the aqueous humor through an opening created at the limbus [28][29]

  • Important consideration: Anterior chamber paracentesis is a temporizing measure; patients will still require definitive treatment with laser peripheral iridotomy. [27]

• Urgent laser peripheral iridotomy (see ''Interventional therapy'' for details)

  • Indication: all patients within 24–48 hours of resolution of the acute attack [6]

Topical pilocarpine becomes effective only once IOP decreases to < 40 mm Hg.

Chronic angle-closure glaucoma with pupillary block should be initially managed with laser surgery (e.g., peripheral iridotomy) or open surgery (iridectomy) to prevent the progression of glaucomatous optic neuropathy and consequent visual field loss. Long-term pharmacotherapy is required if IOP elevation is refractory to the intervention or in patients without pupillary block.

• Laser peripheral iridotomy (LPI): preferred first-line therapy if pupillary block is suspected (see “Interventional therapy” for details) [6][31]

• Maintenance pharmacotherapy: similar to that of open-angle glaucoma (see treatment of open-angle glaucoma for further details) [6]

  • Indications

    • Persistently elevated IOP despite iridotomy

    • Chronic primary angle-closure glaucoma without pupillary block

Acute angle-closure glaucoma and chronic primary angle-closure with pupillary block

• Laser peripheral iridotomy (LPI)

  • Indications

    • Standard of care for acute angle-closure glaucoma as soon as the acute attack is resolved and the cornea becomes clear

    • First-line therapy for chronic primary angle-closure glaucoma with pupillary block

    • Prophylactic therapy for the contralateral eye in patients with unilateral angle-closure glaucoma

  • Procedure: the creation of a hole in the peripheral iris to allow aqueous humor to bypass the pupillary block using a laser (preferably neodymium:YAG)

• Laser peripheral iridoplasty (gonioplasty)

  • Indication: persistently elevated IOP despite a patent LPI

  • Procedure: creation of burn contractures in the peripheral iris with an argon laser to pull the peripheral iris away from the iridocorneal angle

• Surgical peripheral iridectomy

  • Indication: an alternative to LPI in patients with acute/chronic angle-closure glaucoma with pupillary block

  • Procedure: the surgical excision of a small amount of iris tissue to allow for aqueous flow

Chronic primary angle-closure glaucoma without pupillary block

• Interventions are similar to those for open-angle glaucoma. Examples include:

  • Surgical trabeculectomy

  • Tube shunt (aqueous shunt) implantation

Secondary angle-closure glaucoma

• Surgery for the underlying cause, such as:

  • Cataract surgery

  • Goniosynechialysis