Severe acute angle-closure glaucoma: Rapid overview of emergency management

Clinical presentation

Rate of onset and degree of IOP increase determine symptoms

With rapid increase in IOP, patients can experience sudden onset of eye pain, headache, blurry vision, halos around lights, and nausea and/or vomiting; some symptoms may not be present

Episode is often triggered by sudden pupillary dilation from darkness (eg, lights go down in theater), sympathetic arousal (eg, emotional upset), medications

Predisposing medications include: Over-the-counter decongestants, motion sickness medications, adrenergic agents, antipsychotics, antidepressants, and anticholinergics

Examination

Signs associated with rapid increase in IOP include: Reduced visual acuity, red/injected conjunctiva, mid-dilated pupil (4 to 6 mm) that reacts poorly to light or is fixed, corneal edema or cloudiness

Measure IOP: Generally between 40 to 70 mmHg (normal is approximately 8 to 21 mmHg)

Usually one eye is affected at a time, but both eyes must be carefully examined

Management

Obtain emergency ophthalmology consultation for immediate evaluation and to discuss appropriate medical treatment

Place the patient supine

If an ophthalmologist is not available within an hour to confirm the diagnosis, and the patient has a significant decline in vision (eg, with affected eye, patient cannot read text they would normally be able to or cannot count fingers), provide immediate treatment to reduce IOP (consider possible contraindications to medications [eg, beta blocker contraindicated with severe bronchospasm, 2 or 3 degree atrioventricular block, uncompensated heart failure]):

Give timolol 0.5%, one drop to the affected eye, wait one minute, then

Give apraclonidine 1%, one drop to the affected eye, wait one minute, then

Give pilocarpine 2%, one drop to the affected eye, wait one minute, then

Give acetazolamide 500 mg IV (may give by mouth if IV medication not available)

If an ophthalmologist is not available within an hour to confirm the diagnosis, and the patient does NOT have a significant decline in vision, immediate treatment should be withheld UNLESS the IOP is significantly elevated (eg, >40 mmHg)

For all patients, relieve associated symptoms with analgesics (eg, morphine, titrate to effect) and antiemetics (eg, ondansetron, initial dose 8 mg IV)

IOP: intraocular pressure; IV: intravenous.

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Severe acute angle-closure glaucoma: Rapid overview of emergency management