Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Confirm diagnosis with tonometry; initiate topical combo and systemic agents as needed.
- Once IOP falling, add pilocarpine; analgesia/antiemetics as needed.
- Urgent ophthalmology for laser iridotomy; educate on triggers and fellow-eye prophylaxis.
Clinical Synopsis & Reasoning
Severe ocular pain, halos, N/V, and mid-dilated fixed pupil with corneal edema. Begin ED IOP-lowering sequence (topical β-blocker + α-agonist + carbonic anhydrase inhibitor + hyperosmotic agent) and topical pilocarpine once IOP decreased; arrange urgent laser peripheral iridotomy.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Tonometry and slit-lamp exam | Diagnosis | Elevated IOP, shallow AC, corneal edema | — |
| Gonioscopy (when safe) | Confirmation | Closed/narrow angle | — |
| Medication review for precipitants | Etiology | Anticholinergics/sympathomimetics | Stop triggers |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| IOP very high with corneal edema, severe pain, nausea/vomiting | Vision threat | ED IOP-lowering sequence; urgent ophthalmology |
| Monocular functional eye | Disability risk | Admit for close monitoring |
| Delayed access to ophthalmology | Safety | Arrange emergent transfer |
| Anticholinergic/sympathomimetic medication trigger | Drug-induced | Stop offending agents |
| Asian ancestry/hyperopia | Anatomic risk | Prophylaxis of fellow eye |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Topical timolol + apraclonidine/brimonidine + dorzolamide | IOP reduction | Minutes | First-line combo | Contraindications apply |
| Acetazolamide 500 mg IV/PO and Mannitol 1–2 g/kg IV (if severe) | Systemic IOP reduction | Minutes‑hours | Rapid lowering | Renal/CV cautions |
| Pilocarpine 1–2% drops (after initial IOP reduction) | Miotic | Minutes | Open angle via pupillary constriction | Ineffective at very high IOP initially |
| Definitive laser peripheral iridotomy | Definitive | Hours‑days | Prevents recurrence | Prophylaxis for fellow eye |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AAO acute angle-closure management statements — Link