What is the initial management of angle closure glaucoma?

Initial Management of Acute Angle-Closure Glaucoma

The initial management of acute angle-closure glaucoma (AACC) requires immediate medical therapy to lower intraocular pressure (IOP) and relieve symptoms, followed by definitive treatment with laser peripheral iridotomy once the IOP is controlled. 1, 2

Clinical Presentation

Acute angle-closure glaucoma presents with characteristic signs and symptoms:

• Blurred vision and halos around lights due to pressure-induced corneal edema 1, 2
• Mid-dilated pupil 1, 2
• Eye pain and headache 1, 2
• Conjunctival and episcleral vascular congestion (eye redness) 1, 2
• Nausea and/or vomiting 1, 2
• Very high intraocular pressure 1

Initial Medical Management

The immediate goal is to rapidly lower IOP to prevent permanent vision loss:

• Topical beta-adrenergic antagonists (e.g., timolol) to reduce aqueous production 2, 3
• Topical alpha2-adrenergic agonists to decrease aqueous production 2
• Topical carbonic anhydrase inhibitors to reduce aqueous production 2
• Topical parasympathomimetics (e.g., pilocarpine) to constrict the pupil and pull the peripheral iris away from the angle 2, 4
• Oral or intravenous hyperosmotic agents (e.g., mannitol) for severe cases 2

Note: Timolol should not be used alone in angle-closure glaucoma as it has little effect on pupil size 3

Definitive Treatment

Once IOP is controlled with medical therapy:

• Laser peripheral iridotomy (LPI) - creates an opening in the peripheral iris to equalize pressure between the anterior and posterior chambers, eliminating pupillary block 1, 2
• If laser is not available, surgical peripheral iridectomy may be performed 2
• Prophylactic laser iridotomy should be performed in the fellow eye to prevent AACC 1, 2

Alternative Approaches When Standard Treatment Fails

• Argon laser peripheral iridoplasty - contracts the peripheral iris to pull it away from the angle 5
• Anterior chamber paracentesis - provides immediate but temporary IOP reduction in severe cases 5
• Lens extraction - increasingly recognized as an effective treatment, especially in patients with coexisting cataract 1, 2, 6

Management of Plateau Iris

For patients with plateau iris configuration (persistent angle closure despite patent iridotomy):

• Laser iridoplasty may be effective 1
• Long-term miotic therapy may be considered 1
• Lens extraction may be beneficial even without significant cataract 2

Follow-up Care

After initial management:

• Confirm patency of iridotomy 2
• Monitor IOP 2
• Perform gonioscopy to assess the extent of peripheral anterior synechiae (PAS) 2
• Prescribe topical corticosteroids to control post-laser inflammation 2, 7
• Evaluate for persistent IOP elevation that may require additional treatment 2

Important Considerations and Pitfalls

• Delayed diagnosis and treatment can lead to permanent vision loss - 18% of untreated eyes become blind and 48% develop glaucomatous optic neuropathy within 4-10 years 1, 2
• Verify iridotomy patency after LPI, as failure can lead to recurrent attacks 2
• Consider lens extraction in cases with persistent IOP elevation after LPI 1, 2
• Recognize that plateau iris configuration may persist after iridotomy in approximately one-third of cases 1
• Family members should be informed about their risk of angle closure and advised to undergo evaluation 1

Risk Factors for Angle Closure

Understanding risk factors helps identify patients at risk:

• Asian ethnicity (highest rates in Inuit, Chinese, and other Asian populations) 1, 2
• Female gender 2
• Older age (typically over 50 years) 1, 2
• Hyperopia 1, 2
• Shallow anterior chamber depth 1, 2
• Short axial length 1, 2
• Thick crystalline lens 1, 2
• Steep corneal curvature 1, 2
• Family history of angle-closure glaucoma 2