What is the management and treatment for acute glaucoma diagnosis?

Management and Treatment of Acute Glaucoma

Acute angle-closure glaucoma is an ophthalmologic emergency requiring immediate medical therapy to lower intraocular pressure followed by definitive laser iridotomy within hours, not days. 1

Immediate Recognition and Triage

Acute angle-closure crisis (AACC) presents with:

• Severe eye pain, headache, and nausea/vomiting 2
• Markedly elevated intraocular pressure (often >40 mmHg) 2
• Corneal edema, mid-dilated fixed pupil, and conjunctival injection 1
• Visual symptoms including halos around lights and decreased vision 2

Even non-ophthalmologists can diagnose markedly elevated IOP by palpation of the globe—the affected eye feels rock-hard compared to the normal fellow eye. 2 Patients should be seen by an ophthalmologist without delay, ideally on the day of symptom onset. 2

Acute Medical Management

First-Line Medications (Initiate Immediately)

Medical therapy aims to rapidly lower IOP to relieve symptoms and clear corneal edema before definitive laser treatment. 1 Administer the following agents based on the patient's medical status:

Aqueous suppressants:

• Topical beta-adrenergic antagonists (e.g., timolol 0.5%) 1
• Topical alpha-2 agonists (e.g., brimonidine 0.2%) 1
• Topical, oral, or IV carbonic anhydrase inhibitors (acetazolamide 500 mg IV initially, then 250 mg every 4 hours) 1, 3

Hyperosmotic agents for rapid IOP reduction:

• Oral or IV hyperosmotic agents (mannitol 1-2 g/kg IV or oral glycerol) 1

Topical parasympathomimetics (miotics):

• Pilocarpine 1-2% once IOP begins to decrease 1

Critical Medication Considerations

Important caveat: Aqueous suppressants may be initially ineffective because pressure-induced ciliary body ischemia reduces their ability to suppress aqueous formation. 1 Similarly, miotics are frequently ineffective when IOP is markedly elevated due to pressure-induced pupillary sphincter ischemia—they work better once IOP starts declining. 1

Avoid miotics in secondary pupillary block caused by intraocular gas, oil, vitreous, or lens-pupil block—in these cases, mydriatics may be more effective. 1

Definitive Treatment: Laser Peripheral Iridotomy

Laser peripheral iridotomy (LPI) is the preferred definitive treatment and should be performed as soon as the cornea clears enough to visualize the iris. 1 This is typically within hours of initiating medical therapy.

LPI Procedure Details

• LPI relieves pupillary block by allowing aqueous to bypass the pupil, eliminating the pressure gradient between posterior and anterior chambers 1
• Perform LPI in the superior iris (under the upper eyelid) to avoid visual symptoms 1
• Confirm patency by visualizing zonules, anterior lens capsule, or ciliary processes through the iridotomy 1
• Check IOP 30 minutes to 2 hours post-procedure 1

Post-LPI Management

• Prescribe topical corticosteroids postoperatively to reduce inflammation 1
• Perform dark-room gonioscopy with compression/indentation to assess extent of peripheral anterior synechiae (PAS) 1
• Treat the fellow eye prophylactically with LPI because it has similar anatomic predisposition 1

Management of Persistent Elevated IOP After LPI

If IOP remains elevated after successful LPI, consider: 1

Trabecular damage from the acute attack:

• PAS formation during iridocorneal apposition may have permanently damaged outflow 1
• Goniosynechialysis (surgical lysis of synechiae) may improve outflow if performed within 6-12 months 1

Non-pupillary block mechanisms:

• Plateau iris syndrome (persistent angle closure despite patent iridotomy) 1
• Phacomorphic angle closure from lens enlargement 1
• Superimposed open-angle glaucoma or pseudoexfoliation syndrome 1

Additional treatment options:

• Chronic topical ocular hypotensive medications (same as primary open-angle glaucoma) 1
• Laser iridoplasty to reopen appositionally closed angles 1
• Cataract extraction alone can substantially lower IOP in many angle-closure patients and should be considered as a treatment option 1
• Incisional surgery (trabeculectomy or tube shunt) if medical management fails 1

Alternative Acute Interventions

If medical therapy fails or the iris cannot be visualized for LPI: 1

• Corneal indentation with a four-mirror gonioscopic lens, cotton-tipped applicator, or muscle hook tip may break pupillary block 1
• Peripheral laser iridoplasty can be performed if the iris is visible but too edematous for iridotomy 1
• Anterior chamber paracentesis for emergent IOP reduction 1
• Surgical iridectomy if laser treatment is not feasible 1

Common Pitfalls to Avoid

• Do not delay ophthalmology referral to perform additional testing—this is a same-day emergency 2
• Do not rely solely on miotics when IOP is severely elevated; they will not work until pressure decreases 1
• Do not forget to treat the fellow eye prophylactically—it has a 50% risk of acute attack within 5 years 1
• Do not assume the problem is solved after LPI—up to 30% of patients require additional IOP-lowering treatment 1
• Do not confuse this with open-angle glaucoma, which is chronic and asymptomatic, not an acute emergency 4, 5