Acute Angle Closure
As a result of the associated systemic symptoms, acute angle closure glaucoma carries a significant risk of being incorrectly diagnosed - Stephanie Cargnelli
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HWN Suggests
Blind, Aching and Vomiting
If IOP <50 mmHg and there is little visual impairment topical therapy is usually sufficient. The mainstays of urgent management are:
- head up — at least 30 degrees
- topical b-blocker — e.g. timolol 0.5% 1-2 drops as a single dose (caution if bronchospasm or heart failure)
- topical cholinergic (miotic) — e.g pilocarpine 2 or 4 % eyedrops — one-two drops q15min until pupillary constriction occurs (a 2% solution may be better in blue-eyed patients and a 4% solution in brown-eyed patients); especially if angle crowding is suspected.
- topical alpha2-agonist — e.g., apraclonidine 1% 1-2 drops as a single dose.
- acetazolamide 500mg IV, or PO…
Resources
Medical Concepts: Acute Angle Closure Glaucoma
Given the potentially vision compromising nature of this condition, all of these medical treatments should be initiated upon diagnosis. Intraocular pressure should be reassessed hourly to monitor response to treatment. While these pharmacological agents are often effective at lowering the intraocular pressure, patients will often require more definitive management with laser treatment, or occasionally, surgical treatment.
Angle-closure Glaucoma: Are You Ready?
Diagnosing and managing these challenging cases is inevitable. Be prepared with these clinical pearls.
Diagnostics: Elevated Intraocular Pressure
Due to rapidly increasing IOP, the patient with AACG typically presents to the emergency department with a chief complaint of an acutely painful red eye. Risk factors include age greater than 55, hyperopia, being of Inuit or Asian descent and female sex.
Emergency management: angle-closure glaucoma
Acute angle-closure glaucoma is an ophthalmic emergency as it can lead to irreversible blindness if not identified and treated immediately. Treatment goal: immediate lowering of IOP and alleviation of inflammation, pain, nausea.
Blind, Aching and Vomiting
Acute angle closure glaucoma can be primary or secondary. Visual acuity (VA) — decreased Pupil — fixed irregular semidilated (midposition) Slit lamp — shallow AC (closed angle), injected conjunctiva; corneal microcystic edema. Consider secondary causes, e.g. synechiae, neovascularisation. Tonometry — high intraocular pressure (IOP). The eye is tense and tender on palpation. Note that angle-closure glaucoma can occur in the absence of high IOP. Fundoscopy — pronounced cupping or spontaneous arterial pulsations signifies the need for urgent treatment. Rule out CRVO and hemorrhage.
EMdocs
Start with a topical β blocker and alpha 2 agonist +/- diamox. Diamox can be given by mouth if IOP is not excessively elevated (i.e. less than 40). If highly elevated, IV Diamox is preferred. Topical pilocarpine can be considered but should be used with caution 1-2 hours after IOP is reduced for the reasons stated earlier. If IOP is not significantly reduced by 25% at 30-60 minutes, an osmotic agent should be strongly considered. The goal IOP should be 35 or less. Pilocarpine should be given after other eye drops.
RebelEM
These patients require emergent ophthalmology evaluation but treatment should be started empirically while waiting for the evaluation. Initial treatment to decrease IOP usually includes a topical BB such as timolol and topical AB such as apraclonidine and either IV or PO acetazolamide.
Taming the SRU
Acute management of acute ACG in the ED is targeted at reducing the intraocular pressure. There are three mechanisms by which this is achieved: prevention of aqueous humor production, decreasing the volume of vitreous humor and increasing aqueous humor outflow.
Tonometry
IOP is considered one of the “eye vital signs” and should be measured in every patient with an eye complaint or in whom the clinician suspects glaucoma - Gavin Gorrell
WikEM
Goal of medical therapy is to 'break the attack' in order to prepare the patient for laser iridotomy.
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