What is the summary of treatment for Acute Angle-Closure Glaucoma?

From the Guidelines

Acute glaucoma treatment requires immediate medical attention to reduce intraocular pressure and prevent permanent vision loss, with the most recent guidelines from 2021 1 recommending initial management with topical and systemic medications to lower IOP, followed by laser peripheral iridotomy as soon as possible. The initial management of acute angle-closure glaucoma (AACC) involves medical therapy to lower the intraocular pressure (IOP) and relieve acute symptoms, with medications such as:

• Topical beta-adrenergic antagonists
• Topical alpha2-adrenergic agonists
• Topical, oral, or intravenous carbonic anhydrase inhibitors
• Topical parasympathomimetics
• Oral or intravenous hyperosmotic agents According to the 2021 guidelines 1, iridotomy should be performed as soon as possible after the initial medical therapy to eliminate the pressure gradient between the posterior and anterior chambers. Systemic hyperosmotic agents, such as intravenous mannitol, may be necessary to achieve a rapid decrease in IOP in severe cases 1. Laser peripheral iridotomy is the preferred surgical treatment due to its favorable risk-benefit ratio, and it can prevent or retard the formation of peripheral anterior synechiae (PAS) 1. Pain management with oral analgesics is also important for patient comfort. The fellow eye should receive prophylactic laser iridotomy, as it has a high risk of developing acute glaucoma. This comprehensive approach addresses the underlying anatomical issue in acute angle-closure glaucoma, where the peripheral iris blocks the trabecular meshwork, preventing proper drainage of aqueous humor and causing dangerous pressure elevation.

From the FDA Drug Label

For adjunctive treatment of: ... acute angle-closure glaucoma where delay of surgery is desired in order to lower intraocular pressure. 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 or 250 mg every four hours depending on the individual case.

The treatment of acute glaucoma involves the use of acetazolamide as an adjunct to the usual therapy. The dosage is typically 250 mg every four hours, but may vary depending on the individual case. In some cases, an initial dose of 500 mg may be administered, followed by 125 or 250 mg every four hours. Intravenous therapy may be used for rapid relief of ocular tension in acute cases 2 2.

• The treatment should be adjusted with careful individual attention to symptomatology and ocular tension.
• Continuous supervision by a physician is advisable.

From the Research

Treatment Options for Acute Glaucoma

• The treatment of acute glaucoma involves reducing intraocular pressure (IOP) to prevent further optic nerve damage 3, 4, 5, 6.
• Medications used to treat acute glaucoma include miotics, such as pilocarpine, and beta-blockers, such as timolol 3, 7.
• The use of acetazolamide, either intramuscularly or intravenously, has been shown to be effective in reducing IOP in acute closed-angle glaucoma 3.
• Topical timolol alone may not be sufficient to control IOP in acute closed-angle glaucoma, but it can be effective when used in combination with pilocarpine 3.

Adjunctive Therapy and New Management Strategies

• Adjunctive therapy, such as the use of alpha-adrenergic agonists, beta-blockers, and carbonic anhydrase inhibitors, can be used to enhance the effectiveness of primary treatment 4.
• New management strategies, including the use of prostaglandin analogs and selective laser trabeculoplasty, have been shown to be effective in reducing IOP and slowing disease progression 4, 5.
• Minimally invasive glaucoma surgery devices have become more widely used and may be considered as an alternative to traditional surgical methods 5.

Current Management of Glaucoma

• The current management of glaucoma involves a multi-step approach, including the use of medications, laser surgery, and incisional surgical procedures 5, 6.
• The goal of treatment is to reduce IOP and prevent further optic nerve damage, thereby minimizing vision loss 5, 6.
• Regular monitoring and follow-up are essential to ensure that treatment is effective and to make adjustments as needed 6.