What is the appropriate management for a patient presenting with severe pain and nausea, potentially indicative of acute angle-closure glaucoma?

Management of Severe Pain and Nausea Suggestive of Acute Angle-Closure Crisis

Immediately initiate medical therapy to lower intraocular pressure (IOP) with aqueous suppressants (topical beta-blockers, alpha-2 agonists, carbonic anhydrase inhibitors), add parasympathomimetics, and consider osmotic agents if IOP remains critically elevated, followed by urgent laser peripheral iridotomy once IOP is controlled. 1

Immediate Recognition and Assessment

The combination of severe eye pain with nausea strongly suggests acute angle-closure crisis (AACC), a sight-threatening emergency where untreated eyes can develop permanent blindness—18% of AACC eyes become blind within 4-10 years, with 48% developing glaucomatous optic neuropathy. 1, 2

Key clinical features to confirm the diagnosis include: 1

• Pressure-induced corneal edema causing blurred vision and halos around lights
• Mid-dilated, poorly reactive, or oval-shaped pupil
• Conjunctival and episcleral vascular congestion (red eye)
• Markedly elevated IOP (typically >40 mmHg)
• Shallow anterior chamber on examination
• Headache accompanying the eye pain

The nausea and vomiting are systemic manifestations of the acute IOP spike and are pathognomonic when combined with the ocular findings. 2

Critical First Steps

Do not delay treatment waiting for ophthalmology consultation—begin medical therapy immediately upon clinical suspicion, as rapid IOP reduction provides marked symptom relief and prevents irreversible optic nerve damage. 2, 3

Measure IOP immediately by palpation if tonometry is unavailable—even non-ophthalmologists can detect markedly elevated IOP by gentle palpation of the globe through closed eyelids (the eye will feel rock-hard). 3

Medical Treatment Protocol

Administer the following medications urgently: 1, 2

• Topical aqueous suppressants:

  • Beta-blocker (timolol 0.5%)
  • Alpha-2 agonist (apraclonidine 1% or brimonidine 0.2%)
  • Carbonic anhydrase inhibitor (dorzolamide 2% or brinzolamide 1%)

• Parasympathomimetic:

  • Pilocarpine 1-2% (only after IOP begins to decrease, as the ischemic iris may not respond initially)

• Systemic therapy if IOP remains critically elevated:

  • Oral acetazolamide 500 mg
  • IV mannitol or oral glycerol (osmotic agents) if necessary

This multi-agent approach targets different mechanisms of aqueous production and outflow to achieve rapid IOP reduction. 1

Definitive Treatment

Laser peripheral iridotomy (LPI) is the definitive treatment and should be performed urgently once IOP is controlled and corneal clarity improves enough to allow laser penetration. 1, 4 LPI relieves the pupillary block mechanism responsible for most AACC cases by creating an alternative pathway for aqueous flow from posterior to anterior chamber.

Critical: Treat the fellow eye prophylactically with LPI, as untreated fellow phakic eyes have approximately 50% risk of developing AACC within 5 years. 4, 2 Acute attacks can occur within days of the first eye's event. 4

Important Pitfalls to Avoid

Never dilate the pupil in patients with suspected narrow angles or AACC symptoms until after LPI is performed, as dilation can precipitate or worsen acute crisis. 4, 2

Do not dismiss the diagnosis if the patient has bilateral symptoms—primary angle-closure disease is characteristically bilateral, though attacks may not occur simultaneously. 4, 5

Recognize secondary causes: While pupillary block is most common, be aware that certain medications (anticholinergics, adrenergics, sulfa-based drugs including topiramate) can precipitate angle closure. 1, 6, 7 Unilateral presentation should raise suspicion for secondary causes such as choroidal mass or lens subluxation. 8

Risk Factors Supporting the Diagnosis

Patients at highest risk include: 1, 4, 5

• Hyperopic individuals (far-sighted)
• Age over 50 years
• Female gender
• Asian or Inuit ethnicity
• Family history of angle-closure glaucoma
• Short axial length and shallow anterior chamber

Prognosis with Prompt Treatment

When treated immediately, most patients experience rapid symptom relief as IOP decreases. 3 However, the natural history without treatment is devastating—58% of AACC eyes have visual acuity worse than 20/40 within 4-10 years. 1, 2 This underscores the critical importance of immediate recognition and treatment, followed by definitive LPI to prevent recurrence and protect the fellow eye.