What is the management plan for a patient with rising intraocular pressure (IOP) following a traumatic injury?

Management of Rising Intraocular Pressure Following Traumatic Injury

Immediately initiate aggressive aqueous suppression with topical beta-blockers, carbonic anhydrase inhibitors, and alpha-2 agonists to prevent irreversible optic nerve damage, while urgently identifying the specific mechanism of IOP elevation within hours to guide definitive treatment. 1

Immediate Medical Management

The priority is rapid IOP reduction to prevent optic nerve damage. Start combination therapy immediately:

• Topical timolol 0.5% twice daily as first-line beta-blocker for maximum aqueous suppression 1, 2
• Add topical carbonic anhydrase inhibitors (dorzolamide or brinzolamide) for an additional 15-20% IOP reduction 1
• Topical alpha-2 agonists (brimonidine 0.2%) to reduce aqueous production and increase uveoscleral outflow 1, 2

For critically elevated pressures (>40 mmHg):

• Oral or intravenous carbonic anhydrase inhibitors (acetazolamide) for rapid IOP reduction 3, 1
• Oral or intravenous hyperosmotic agents (mannitol or glycerol) for immediate pressure reduction in emergency situations 3, 1

Critical Monitoring Protocol

Check IOP within 30 minutes to 2 hours after initiating treatment, then every 2-4 hours until below 30 mmHg. 3, 1 The target IOP is less than 21 mmHg to prevent further optic nerve damage. 1

Perform these assessments as soon as clinically feasible:

• Slit-lamp examination to identify retained viscoelastic, lens damage, or anterior chamber abnormalities 1
• Gonioscopy once corneal clarity permits to assess angle status and identify synechiae or angle recession 3, 1
• Optic nerve examination for acute ischemic damage or pre-existing glaucomatous changes 1

Mechanism-Specific Management

The specific cause of IOP elevation determines definitive treatment:

Pupillary Block

• Perform laser peripheral iridotomy as soon as possible if pupillary block is confirmed 3
• Ensure iridotomy patency by directly visualizing aqueous and pigment flow from posterior to anterior chamber 3
• Enlarge iridotomy to at least 100 microns diameter 3

Angle Closure with Synechiae

• Consider goniosynechialysis if performed within 6-12 months of injury to reopen synechially closed angles 3
• If extensive synechial closure persists, manage as primary open-angle glaucoma with chronic topical agents 3

Trabecular Damage

• Traumatic IOP elevation develops in 23.3% of open-globe injuries, with most cases occurring within 6 months 4
• Older age and vitreous hemorrhage are significant risk factors for developing traumatic glaucoma 4
• Treat similarly to primary open-angle glaucoma with chronic topical ocular hypotensive agents 3

Surgical Intervention Thresholds

Consider urgent surgical intervention if IOP remains above 40 mmHg despite maximum medical therapy for 2-4 hours. 1

Additional surgical indications:

• Confirmed pupillary block where laser iridotomy fails or cannot be performed 1
• Extensive synechial angle closure requiring trabeculectomy or tube shunt 3, 1
• Malignant glaucoma (rare but reported post-trauma) requiring pars plana vitrectomy 5

Critical Pitfalls to Avoid

High IOP does not exclude open globe injury—16.2% of open globe injuries present with IOP >21 mmHg, particularly with posterior injuries. 6 Do not delay surgical repair based on IOP readings alone.

Steroid-induced IOP elevation is common in the post-traumatic period when corticosteroids are used for inflammation control. 5 Monitor IOP closely during steroid therapy and taper cautiously. 1

Retained viscoelastic can cause IOP spikes if the injury required surgical intervention with viscoelastic use. 1, 5 This typically presents within days and may require anterior chamber washout.

Missed pre-existing glaucoma may be unmasked by trauma—always compare with fellow eye IOP and assess for baseline optic nerve damage. 5

Long-Term Follow-Up

After acute crisis resolution:

• Follow-up at 1 day, 1 week, 2 weeks, 1 month, then every 3 months for the first year 1
• Assess for permanent glaucomatous damage requiring long-term monitoring 1
• Most traumatic IOP elevation develops within 6 months, but longer follow-up remains important for case detection 4
• Approximately 6.2% of open-globe injuries develop traumatic glaucoma requiring long-term medication or surgery 4