Acute angle-closure glaucoma - Revision history

Danbot: Strip excess bold

2026-03-22T09:35:40Z

Strip excess bold

← Older revision		Revision as of 09:35, 22 March 2026
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	*Sudden increase in [[intraocular pressure]] (IOP) due to obstruction of aqueous humor outflow through the trabecular meshwork		*Sudden increase in [[intraocular pressure]] (IOP) due to obstruction of aqueous humor outflow through the trabecular meshwork
	*'''Ophthalmologic emergency''' — permanent vision loss can occur within hours		*'''Ophthalmologic emergency''' — permanent vision loss can occur within hours
	*Normal IOP: 10-21 mmHg; in acute attack: typically ~~'''~~40-80 mmHg~~'''~~		*Normal IOP: 10-21 mmHg; in acute attack: typically 40-80 mmHg
	*Pathophysiology:		*Pathophysiology:
	**Pupillary dilation → peripheral iris contacts trabecular meshwork → blocks aqueous outflow		**Pupillary dilation → peripheral iris contacts trabecular meshwork → blocks aqueous outflow
	**Increased posterior chamber pressure → iris bows forward (~~'''~~iris bombe~~'''~~) → further obstruction		**Increased posterior chamber pressure → iris bows forward (iris bombe) → further obstruction
	*Risk factors:		*Risk factors:
	**Hyperopia (farsightedness — smaller anterior chamber)		**Hyperopia (farsightedness — smaller anterior chamber)
	**~~'''~~Asian~~'''~~ and Inuit descent (anatomically shallow anterior chambers)		**Asian and Inuit descent (anatomically shallow anterior chambers)
	**Female sex, age >40		**Female sex, age >40
	**Family history		**Family history
	*~~'''~~Precipitants~~'''~~: dim lighting, medications causing mydriasis (anticholinergics, sympathomimetics, topiramate), emotional stress		*Precipitants: dim lighting, medications causing mydriasis (anticholinergics, sympathomimetics, topiramate), emotional stress

	==Clinical Features==		==Clinical Features==
	[[File:Ciliary flush acute angle closure.jpg\|thumb\|Ciliary/circumcorneal flush and hazy cornea characteristic of acute angle closure glaucoma.]]		[[File:Ciliary flush acute angle closure.jpg\|thumb\|Ciliary/circumcorneal flush and hazy cornea characteristic of acute angle closure glaucoma.]]
	[[File:Acute angle closure pupil.jpg\|thumb\|Right eye with mid-sized, fixed pupil and ciliary flush.]]		[[File:Acute angle closure pupil.jpg\|thumb\|Right eye with mid-sized, fixed pupil and ciliary flush.]]
	*~~'''~~Sudden onset, severe unilateral eye pain~~'''~~		*Sudden onset, severe unilateral eye pain
	*~~'''~~Blurred vision~~'''~~ with ~~'''~~"halos" around lights~~'''~~ (corneal edema)		*Blurred vision with "halos" around lights (corneal edema)
	*~~'''~~Frontal or supraorbital headache~~'''~~		*Frontal or supraorbital headache
	*~~'''~~Nausea and vomiting~~'''~~ (may be prominent → misdiagnosed as GI illness)		*Nausea and vomiting (may be prominent → misdiagnosed as GI illness)
	*~~'''~~Fixed, mid-dilated pupil~~'''~~ (oval or irregular)		*Fixed, mid-dilated pupil (oval or irregular)
	*~~'''~~Hazy, edematous cornea~~'''~~ (steamy appearance)		*Hazy, edematous cornea (steamy appearance)
	*~~'''~~Ciliary flush~~'''~~ (conjunctival injection most prominent at limbus)		*Ciliary flush (conjunctival injection most prominent at limbus)
	*~~'''~~Rock-hard globe~~'''~~ on palpation (elevated IOP)		*Rock-hard globe on palpation (elevated IOP)
	*~~'''~~Decreased visual acuity~~'''~~		*Decreased visual acuity

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
	*~~'''~~IOP measurement~~'''~~ (Tono-Pen or Goldmann):		*IOP measurement (Tono-Pen or Goldmann):
	**~~'''~~IOP >21 mmHg~~'''~~ (typically >40 mmHg in acute attack)		**IOP >21 mmHg (typically >40 mmHg in acute attack)
	*~~'''~~Slit lamp exam~~'''~~:		*Slit lamp exam:
	**Shallow anterior chamber		**Shallow anterior chamber
	**Corneal edema		**Corneal edema
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	===Diagnostic Criteria: 3 Signs + 2 Symptoms===		===Diagnostic Criteria: 3 Signs + 2 Symptoms===
	*At least ~~'''~~3 signs~~'''~~: IOP >21 mmHg, conjunctival injection, corneal epithelial edema, mid-dilated nonreactive pupil, shallow anterior chamber		*At least 3 signs: IOP >21 mmHg, conjunctival injection, corneal epithelial edema, mid-dilated nonreactive pupil, shallow anterior chamber
	*At least ~~'''~~2 symptoms~~'''~~: ocular pain, nausea/vomiting, history of intermittent blurring with halos		*At least 2 symptoms: ocular pain, nausea/vomiting, history of intermittent blurring with halos

	==Management==		==Management==
	*~~'''~~Goal: rapidly lower IOP to prepare for definitive laser iridotomy~~'''~~<ref>Primary Angle Closure Preferred Practice Pattern. American Academy of Ophthalmology. 2016.</ref>		*Goal: rapidly lower IOP to prepare for definitive laser iridotomy<ref>Primary Angle Closure Preferred Practice Pattern. American Academy of Ophthalmology. 2016.</ref>
	*~~'''~~Emergent ophthalmology consult~~'''~~		*Emergent ophthalmology consult
	*~~'''~~Recheck IOP at least hourly~~'''~~		*Recheck IOP at least hourly
	*~~'''~~Position~~'''~~: elevate head of bed, keep room ~~'''~~well-lit~~'''~~ (promotes miosis)		*Position: elevate head of bed, keep room well-lit (promotes miosis)
	*~~'''~~Start simultaneously with topical beta-blocker, alpha-2 agonist, and systemic carbonic anhydrase inhibitor~~'''~~		*Start simultaneously with topical beta-blocker, alpha-2 agonist, and systemic carbonic anhydrase inhibitor

	===Decrease Aqueous Humor Production===		===Decrease Aqueous Humor Production===
	*~~'''~~Timolol 0.5%~~'''~~: 1 drop in affected eye; repeat in 1 hour if needed		*Timolol 0.5%: 1 drop in affected eye; repeat in 1 hour if needed
	**Contraindicated in severe asthma/COPD, bradycardia, heart block		**Contraindicated in severe asthma/COPD, bradycardia, heart block
	*~~'''~~Acetazolamide 500 mg IV or PO~~'''~~ (PO preferred unless nauseated)		*Acetazolamide 500 mg IV or PO (PO preferred unless nauseated)
	**Contraindicated in '''sickle cell disease''' (promotes sickling in acidic environment)		**Contraindicated in '''sickle cell disease''' (promotes sickling in acidic environment)
	**Substitute methazolamide 100 mg if renal failure		**Substitute methazolamide 100 mg if renal failure
	*~~'''~~Dorzolamide 2%~~'''~~: topical carbonic anhydrase inhibitor — 1 drop affected eye		*Dorzolamide 2%: topical carbonic anhydrase inhibitor — 1 drop affected eye

	===Alpha-2 Agonist===		===Alpha-2 Agonist===
	*~~'''~~Brimonidine 0.2%~~'''~~ OR ~~'''~~apraclonidine 1%~~'''~~: 1 drop affected eye		*Brimonidine 0.2% OR apraclonidine 1%: 1 drop affected eye
	**Reduces aqueous production and increases trabecular outflow		**Reduces aqueous production and increases trabecular outflow

	===Facilitate Aqueous Outflow===		===Facilitate Aqueous Outflow===
	*~~'''~~Pilocarpine 1-2%~~'''~~: 1 drop affected eye every 15 min x 2-4 doses, then q4-6h		*Pilocarpine 1-2%: 1 drop affected eye every 15 min x 2-4 doses, then q4-6h
	**Parasympathomimetic → miosis → pulls iris away from trabecular meshwork		**Parasympathomimetic → miosis → pulls iris away from trabecular meshwork
	**'''Likely ineffective until IOP drops below 40-50 mmHg''' (ischemic sphincter muscle) — give immediately anyway		**'''Likely ineffective until IOP drops below 40-50 mmHg''' (ischemic sphincter muscle) — give immediately anyway
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	===Reduce Vitreous Volume (Refractory Cases)===		===Reduce Vitreous Volume (Refractory Cases)===
	*~~'''~~Mannitol 1-2 g/kg IV~~'''~~ over 45 minutes (most common hyperosmotic agent)		*Mannitol 1-2 g/kg IV over 45 minutes (most common hyperosmotic agent)
	**Contraindicated in renal failure; can cause hypotension		**Contraindicated in renal failure; can cause hypotension
	*~~'''~~50% glycerin or 45% isosorbide 1.5 mL/kg PO~~'''~~ (rarely used)		*50% glycerin or 45% isosorbide 1.5 mL/kg PO (rarely used)

	===Topical Steroids===		===Topical Steroids===
	*~~'''~~Prednisolone acetate 1%~~'''~~: 1 drop q15-30min x 4, then q1h		*Prednisolone acetate 1%: 1 drop q15-30min x 4, then q1h
	**Not during acute attack; consider '''after IOP controlled''' to reduce inflammation<ref>Guluma K, Lee JE. Ophthalmology. In: ''Rosen's Emergency Medicine''. 9th ed. Elsevier; 2018.</ref>		**Not during acute attack; consider '''after IOP controlled''' to reduce inflammation<ref>Guluma K, Lee JE. Ophthalmology. In: ''Rosen's Emergency Medicine''. 9th ed. Elsevier; 2018.</ref>

	==Disposition==		==Disposition==
	*~~'''~~Admit~~'''~~ for definitive treatment with ~~'''~~laser peripheral iridotomy~~'''~~ (definitive cure)		*Admit for definitive treatment with laser peripheral iridotomy (definitive cure)
	*~~'''~~Prophylactic iridotomy~~'''~~ of the fellow (unaffected) eye is standard practice		*Prophylactic iridotomy of the fellow (unaffected) eye is standard practice
	*Ophthalmology follow-up within 24 hours		*Ophthalmology follow-up within 24 hours

Danbot: Major update: pilocarpine ineffective until IOP <40-50, sickle cell contraindication, simultaneous multidrug approach, prophylactic fellow eye iridotomy, medication timing, references with PMIDs

2026-03-21T19:57:54Z

Major update: pilocarpine ineffective until IOP <40-50, sickle cell contraindication, simultaneous multidrug approach, prophylactic fellow eye iridotomy, medication timing, references with PMIDs

Show changes

Danbot: Add MedicationDose entries (timolol, acetazolamide, pilocarpine) with SMW annotations

2026-03-20T18:27:14Z

Add MedicationDose entries (timolol, acetazolamide, pilocarpine) with SMW annotations

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 *Topical steroids not indicated during acute attack, but may help inflammation after IOP under control.
 **[[Prednisolone]] acetate 1% 1 gtt every 15 to 30 minutes four times, then q1h <ref>Guluma, K., & Lee, J. E. (2018). Ophthalmology. In Rosen's Emergency Medicine: Concepts and Clinical Practice (9th ed.). Philadephia, PA: Elsevier/Saunders.</ref>
 ==Disposition==

Rossdonaldson1 at 18:04, 4 February 2026

2026-02-04T18:04:15Z

← Older revision		Revision as of 18:04, 4 February 2026
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	==Background==		==Background==
			[[ File:Gray883.png\|thumb\|Eye angle anatomy.]]
	[[File:PMC4614311 qmj-2015-01-0006-g002.png\|thumb\|Mechanism of acute angle closure.]]		[[File:PMC4614311 qmj-2015-01-0006-g002.png\|thumb\|Mechanism of acute angle closure.]]
	[[File:PMC3991910 1471-2431-14-96-1.png\|thumb\|A. Slit lamp exam of the right eye demonstrating diffusely shallow AC, large pupil, and slightly injected conjunctiva. B. Normal slit lamp photograph of the right eye after resolution of acute angle closure C. Anterior segment of the right eye demonstrating abnormal anterior iris convexity, iridocorneal apposition at the angle, and an anterior lens vault D. Normal anterior segment of the right eye demonstrating horizontal iris, no iridocorneal apposition, anterior iris convexity, or anterior lens vault.]]		[[File:PMC3991910 1471-2431-14-96-1.png\|thumb\|A. Slit lamp exam of the right eye demonstrating diffusely shallow AC, large pupil, and slightly injected conjunctiva. B. Normal slit lamp photograph of the right eye after resolution of acute angle closure C. Anterior segment of the right eye demonstrating abnormal anterior iris convexity, iridocorneal apposition at the angle, and an anterior lens vault D. Normal anterior segment of the right eye demonstrating horizontal iris, no iridocorneal apposition, anterior iris convexity, or anterior lens vault.]]

Cmb23: /* Facilitate outflow of aqueous humor */

2023-10-02T01:20:09Z

Facilitate outflow of aqueous humor

← Older revision		Revision as of 01:20, 2 October 2023
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	*1 drop in affected eye every 15 minutes x 2-4 doses, then every 4 to 6 hours		*1 drop in affected eye every 15 minutes x 2-4 doses, then every 4 to 6 hours
	*Likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis		*Likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis
	*High-concentration pilocarpine (4%) should ~~note~~ be given because it can cause forward displacement of the iris-lens diaphragm.		*High-concentration pilocarpine (4%) should NOT be given because it can cause forward displacement of the iris-lens diaphragm.
	*'''Note:''' may make fundoscopic evaluation more difficult for ophtho consultant due to miosis		*'''Note:''' may make fundoscopic evaluation more difficult for ophtho consultant due to miosis

Cmb23: /* Facilitate outflow of aqueous humor */

2023-10-02T01:19:41Z

Facilitate outflow of aqueous humor

← Older revision		Revision as of 01:19, 2 October 2023
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	*1 drop in affected eye every 15 minutes x 2-4 doses, then every 4 to 6 hours		*1 drop in affected eye every 15 minutes x 2-4 doses, then every 4 to 6 hours
	*Likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis		*Likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis
			*High-concentration pilocarpine (4%) should note be given because it can cause forward displacement of the iris-lens diaphragm.
	*'''Note:''' may make fundoscopic evaluation more difficult for ophtho consultant due to miosis		*'''Note:''' may make fundoscopic evaluation more difficult for ophtho consultant due to miosis

Muathas: /* Facilitate outflow of aqueous humor */

2023-07-17T06:08:24Z

Facilitate outflow of aqueous humor

← Older revision		Revision as of 06:08, 17 July 2023
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	===Facilitate outflow of aqueous humor===		===Facilitate outflow of aqueous humor===
	'''Pilocarpine 1%–2%:'''		'''Pilocarpine 1%–2%:'''
	*~~Parasympatholytic alkaloid~~ acts on muscarinic receptors found on iris sphincter muscle → causes muscle to contract → miosis → pulls iris away from trabecular network		*Parasympathomimetic acts on muscarinic receptors found on iris sphincter muscle → causes muscle to contract → miosis → pulls iris away from trabecular network
	*1 drop in affected eye every 15 minutes x 2-4 doses, then every 4 to 6 hours		*1 drop in affected eye every 15 minutes x 2-4 doses, then every 4 to 6 hours
	*Likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis		*Likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis

Rossdonaldson1: /* See Also */

2022-02-05T12:24:51Z

Elcatracho: /* Disposition */

2021-02-10T02:18:34Z

Disposition

← Older revision		Revision as of 02:18, 10 February 2021
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	==Disposition==		==Disposition==
			*Admit for definitive therapy with iridotomy

	==See Also==		==See Also==

Rossdonaldson1: /* Evaluation */

2020-09-26T17:44:13Z

Evaluation

← Older revision		Revision as of 17:44, 26 September 2020
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	[[File:PMC4614311 qmj-2015-01-0006-g001.png\|thumb\|(A) shallow anterior chamber at presentation (B) closed iridocorneal angles on gonioscopy.]]		[[File:PMC4614311 qmj-2015-01-0006-g001.png\|thumb\|(A) shallow anterior chamber at presentation (B) closed iridocorneal angles on gonioscopy.]]
	*[[intraocular pressure\|IOP]] >20 mm Hg		*[[intraocular pressure\|IOP]] >20 mm Hg
	*Slit lamp exam shows shallow anterior chamber and ''cell and flare''		*[[Slit lamp exam]] shows shallow anterior chamber and ''cell and flare''

	===Definition: 3 signs + 2 symptoms===		===Definition: 3 signs + 2 symptoms===

← Older revision		Revision as of 12:24, 5 February 2022
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	*[[Eye Algorithm (Main)]]		*[[Eye Algorithm (Main)]]
	*[[Tono-Pen use]]		*[[Tono-Pen use]]
			*[[Open-angle glaucoma]]

	==References==		==References==