What is the management approach for a patient presenting with unilateral eye pain and vomiting, suspected of having acute angle-closure glaucoma?

Management of Unilateral Eye Pain with Vomiting

Treat this as acute angle-closure glaucoma (AACG) until proven otherwise—immediately measure intraocular pressure (IOP), initiate medical therapy to lower IOP, and arrange emergent ophthalmology consultation for laser peripheral iridotomy (LPI). 1, 2

Immediate Assessment and Recognition

The combination of unilateral eye pain with vomiting is a classic presentation of acute angle-closure crisis, which can cause irreversible blindness within hours if untreated. 2

Key diagnostic features to confirm AACG:

• Markedly elevated IOP (typically >40 mmHg) 2
• Mid-dilated, poorly reactive or fixed pupil (may appear oval or asymmetric) 1, 2
• Corneal edema creating a "steamy" or hazy appearance 2
• Shallow anterior chamber on slit-lamp examination 1, 2
• Conjunctival injection (red eye) from vascular congestion 2
• Associated symptoms: Blurred vision, halos around lights, severe headache, nausea/vomiting 1, 2

Critical pitfall: Do not delay treatment waiting for ophthalmology consultation—18% of untreated eyes become blind within 4-10 years, and glaucomatous optic neuropathy can develop rapidly. 1, 2

Immediate Medical Management

Begin aggressive IOP-lowering therapy immediately upon suspicion: 1, 2

• Topical beta-blocker (e.g., timolol 0.5%) 1
• Topical alpha-2 agonist (e.g., apraclonidine 1% or brimonidine 0.2%) 1
• Topical carbonic anhydrase inhibitor (e.g., brinzolamide or dorzolamide) 1, 3
• Oral or IV carbonic anhydrase inhibitor (e.g., acetazolamide 500mg IV or PO) 1
• Oral or IV hyperosmotic agent (e.g., mannitol 1-2 g/kg IV or oral glycerol) 1
• Topical pilocarpine 1-2% (only after IOP begins to decrease, as ischemic ciliary body may not respond initially) 1

Important caveat: Aqueous suppressants like brinzolamide may have decreased effectiveness initially if the ciliary body is ischemic from the pressure spike. 3

Definitive Treatment

Laser peripheral iridotomy (LPI) is the definitive treatment once IOP is controlled, as it relieves pupillary block and prevents recurrence. 1, 2, 4

Both eyes require evaluation and prophylactic treatment: The fellow eye has approximately 50% risk of developing acute angle-closure crisis within 5 years if left untreated. 1, 4

Critical Differential Diagnoses to Exclude

Before committing to AACG diagnosis, rapidly exclude these life-threatening conditions:

Subarachnoid hemorrhage with third nerve palsy:

• Look for ptosis, exotropia, hypotropia, and fixed mydriasis 5
• The fixed dilated pupil from third nerve palsy can precipitate angle closure 5
• If neurological signs of increased intracranial pressure or cranial nerve palsies are present, obtain emergent neuroimaging 5

Central retinal artery occlusion:

• Presents with sudden painless vision loss (not painful), normal IOP, no corneal edema 2
• Requires immediate stroke center referral due to high risk of concurrent cerebral infarction 2

Medication History Assessment

Inquire specifically about drugs that can precipitate angle closure: 1

Anticholinergic agents:

• Topical mydriatics (tropicamide, atropine) 6, 7
• Tricyclic/tetracyclic antidepressants 6
• Over-the-counter cold/flu medications containing anticholinergics 7
• Periocular botulinum toxin 6

Adrenergic agents:

• Phenylephrine drops, nasal ephedrine, nebulized salbutamol 6
• Herbal medications containing Ma-huang (Ephedra) 8

Sulfa-based drugs (cause angle closure via ciliary body edema, not pupillary block):

• Topiramate, acetazolamide, hydrochlorothiazide, cotrimoxazole 1, 6
• Critical distinction: These cause anterior rotation of iris-lens diaphragm; iridotomy is NOT effective 6

Natural History Without Treatment

The prognosis of untreated AACG is devastating: 1, 2

• 48% develop glaucomatous optic neuropathy 1
• 58% have visual acuity worse than 20/40 1
• 18% become blind (50% of blindness from glaucoma) 1
• These outcomes occur within 4-10 years following an acute attack 1

Post-Acute Management

After LPI, monitor for persistent IOP elevation: 1, 3

• Some patients develop chronic angle closure requiring ongoing medical therapy with agents like brinzolamide 3
• Lens extraction may be an effective alternative treatment for patients with persistent angle closure after LPI 1, 3
• Perform gonioscopy to confirm angle opening after intervention 1

Patient and family education: 1

• Inform genetically related family members they are at risk and should be evaluated 1
• Avoid pupil dilation until after iridotomy is performed 2, 4
• Recognize warning symptoms of intermittent angle closure (transient blurred vision, halos, eye pain) 4