What is the initial treatment for acute angle closure glaucoma?

From the Guidelines

The initial treatment for acute angle closure glaucoma is immediate lowering of intraocular pressure through a combination of medications, as recommended by the most recent guidelines 1. This approach typically includes topical beta-blockers, alpha-2 agonists, and topical or oral carbonic anhydrase inhibitors.

• Topical beta-adrenergic antagonists, such as timolol 0.5%, are often used to reduce intraocular pressure.
• Topical alpha2-adrenergic agonists, such as brimonidine 0.2%, can also be effective in lowering IOP.
• Topical, oral, or intravenous carbonic anhydrase inhibitors, like acetazolamide 500mg orally or IV, are commonly used to decrease aqueous humor formation. Additional treatments may include:
• Hyperosmotic agents, such as mannitol (1-2g/kg IV) or glycerol (1-1.5g/kg orally), to rapidly reduce IOP in severe cases.
• Topical parasympathomimetics, like pilocarpine 2-4%, which may be added after the initial pressure decrease.
• Topical steroids to reduce inflammation.
• Oral analgesics for pain management. The primary goal of this aggressive medical therapy is to rapidly reduce intraocular pressure and prevent permanent vision loss from optic nerve damage, as emphasized in the latest guidelines 1. Once the acute attack is controlled, definitive treatment with laser peripheral iridotomy is necessary, usually within 24-48 hours, to create a bypass channel that prevents future attacks 1. The fellow eye should also receive prophylactic iridotomy since it has a high risk of developing a similar attack. It is essential to note that the configuration of the iris and the presence of secondary pupillary block may affect the choice of treatment, and systemic hyperosmotic agents or corneal indentation may be necessary in some cases 1. Laser iridotomy is the preferred surgical treatment due to its favorable risk-benefit ratio, and it can relieve pupillary block, prevent or retard the formation of PAS, and result in significant angle widening and iris-profile flattening 1.

From the FDA Drug Label

In treatment of secondary glaucoma and in the preoperative treatment of some cases of acute congestive (closed-angle) glaucoma, the preferred dosage is 250 mg every four hours, although some cases have responded to 250 mg twice daily on short-term therapy In some acute cases, it may be more satisfactory to administer an initial dose of 500 mg followed by 125 mg or 250 mg every four hours depending on the individual case. Intravenous therapy may be used for rapid relief of ocular tension in acute cases.

The initial treatment for acute angle closure glaucoma may include intravenous acetazolamide. The dosage can be an initial dose of 500 mg followed by 125 mg or 250 mg every four hours, depending on the individual case 2 2.

From the Research

Initial Treatment for Acute Angle Closure Glaucoma

The initial treatment for acute angle closure glaucoma involves several steps to reduce intraocular pressure (IOP) and prevent further damage to the optic nerve. Some key points to consider include:

• Reducing IOP medically and/or by laser iridoplasty 3
• Using medications such as acetazolamide, pilocarpine, and timolol to lower IOP 4
• Performing laser peripheral iridotomy (PI) on both the affected and fellow eye to eliminate pupillary block 3

Medical Treatment

Medical treatment for acute angle closure glaucoma typically involves the use of:

• Acetazolamide to reduce aqueous humor production 4
• Pilocarpine to constrict the pupil and open the anterior chamber angle 4
• Timolol to reduce aqueous humor production and lower IOP 4
• Note that pilocarpine should be used with caution in certain situations, as it can induce acute angle closure in some cases 5

Surgical Treatment

Surgical treatment for acute angle closure glaucoma may involve:

• Laser peripheral iridotomy (PI) to create a hole in the iris and allow aqueous humor to flow through 3
• Laser iridoplasty to contract the iris and open the anterior chamber angle 3
• Trabeculectomy or other filtration surgeries to create a new drainage path for aqueous humor 3
• Lens extraction or combined lens extraction with trabeculectomy and goniosynechialysis in certain cases 3