From the Guidelines
Acute angle-closure glaucoma is a serious eye emergency requiring immediate medical attention, and initial treatment typically includes eye drops such as timolol 0.5% and oral or intravenous medications like acetazolamide 500mg to rapidly lower intraocular pressure, followed by definitive treatment with laser peripheral iridotomy 1.
Key Considerations
- The condition occurs when the drainage angle between the iris and cornea suddenly closes, blocking fluid outflow and rapidly increasing eye pressure.
- Risk factors include being farsighted, Asian ancestry, older age, female gender, and having a family history of the condition.
- Symptoms include severe eye pain, headache, blurry vision, seeing halos around lights, nausea, vomiting, and redness of the eye.
Treatment Approach
- Initial treatment aims to lower intraocular pressure (IOP) to relieve acute symptoms and prevent further damage.
- Medical therapy includes topical beta-adrenergic antagonists, topical alpha2-adrenergic agonists, topical, oral, or intravenous carbonic anhydrase inhibitors, topical parasympathomimetics, and oral or intravenous hyperosmotic agents 1.
- Laser peripheral iridotomy is the preferred surgical treatment, as it has a favorable risk-benefit ratio and can prevent or retard the formation of peripheral anterior synechiae (PAS) 1.
Fellow Eye Management
- The fellow eye of a patient with acute angle-closure glaucoma should be evaluated promptly, as it is at high risk for a similar event.
- Prophylactic laser iridotomy is recommended for the fellow eye if the chamber angle is anatomically narrow, as it can prevent acute angle closure 1.
From the FDA Drug Label
INDICATIONS AND USAGE: ... In acute (closed-angle) glaucoma, pilocarpine hydrochloride may be used alone, or in combination with other cholinergic agents or carbonic anhydrase inhibitors, to relieve tension prior to emergency surgery.
- Pilocarpine hydrochloride can be used in the management of acute angle glaucoma to relieve tension before emergency surgery.
- It may be used alone or in combination with other agents. 2
From the Research
Definition and Diagnosis of Acute Angle Glaucoma
- Acute angle-closure glaucoma is an uncommon disorder that must be diagnosed and managed quickly and effectively to prevent visual loss 3.
- Several conditions may appear as an acute angle-closure glaucoma and must be recognized since, in certain cases, treatment may be different from that required for an acute angle-closure attack 3.
Treatment Options for Acute Angle Glaucoma
- The hypotensive effect of intramuscular or intravenous acetazolamide with frequent instillation of 2% or 4% pilocarpine in polyvinyl alcohol, or with single drops of pilocarpine in polyvinyl alcohol or oily vehicles, and the hypotensive effect of topical timolol alone and together with pilocarpine was investigated in the treatment of acute closed-angle glaucoma in 75 patients (81 eyes) 4.
- Topical timolol alone was not effective enough to control the intraocular pressure in acute closed-angle glaucoma, but a good hypotensive effect was seen when topical timolol was followed by pilocarpine 4.
- Laser peripheral iridotomy (LPI) has been found to be as effective as surgical peripheral iridectomy in randomized clinical trials of the affected and contralateral eyes of AAC or PAC patients with or without evidence of glaucoma 5.
- In patients with PAC and insufficient treatment with LPI, latanoprost eye drops may decrease IOP more than timolol 5.
Case Reports and Studies
- A case report describes a topiramate induced acute bilateral angle-closure glaucoma, which is a rare adverse effect characterized by uveal effusion and lens forward displacement, leading to increased intraocular pressure and vision loss 6.
- A retrospective study assessed primary therapeutic measures in 94 eyes suffering from acute angle-closure glaucoma, and found that therapy without pilocarpine proved to be significantly more effective 7.
Management and Prevention
- Once an acute angle-closure attack has been successfully managed through medical treatment, a laser iridotomy is indicated to prevent an attack from recurring 3.
- 1 drop of pilocarpine 3 hours after intravenous or intramuscular acetazolamide or after topical timolol may be sufficient to terminate an acute attack 4.