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
- Start topical combo + systemic acetazolamide; add mannitol if refractory.
- Once IOP decreases, give pilocarpine; arrange urgent laser iridotomy (both eyes often treated).
- Address precipitants/meds; close follow-up with ophthalmology.
Clinical Synopsis & Reasoning
Severe eye pain, halos, headache, and nausea with mid-dilated fixed pupil and corneal edema. Start immediate pressure-lowering regimen (topical beta-blocker, alpha-agonist, carbonic anhydrase inhibitor; systemic acetazolamide ± hyperosmotic agent), then pilocarpine once IOP lowered; arrange urgent laser 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, corneal edema, shallow anterior chamber | — |
| Gonioscopy (ophthalmology) | Confirmation | Closed angle | — |
| Basic labs (if systemic therapy) | Safety | Renal function prior to acetazolamide | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| IOP very high with severe pain/vision loss | Optic nerve damage risk | Immediate multi-drug regimen; emergent ophthalmology |
| No response to medical therapy | Ongoing ischemia | Laser/surgical intervention now |
| Secondary causes (phacomorphic, uveitis) | Different pathway | Tailored management; admit |
| Only seeing eye | Vision-threatening | Admit for expedited care |
| Medication nonadherence risk | Recurrence/progression | Education and close follow-up |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Timolol 0.5% + Apraclonidine 1% drops | Topical IOP lowering | Minutes | Initial combo | Contraindications apply |
| Acetazolamide 500 mg PO/IV | Carbonic anhydrase inhibitor | Hours | Systemic IOP reduction | Avoid in severe renal disease |
| Mannitol 1–2 g/kg IV (if refractory) | Hyperosmotic | Hours | Further IOP drop | Watch for HF/renal failure |
| Pilocarpine 1–2% (after IOP lowered) | Miotic | Minutes | Opens trabecular outflow | Avoid initially if IOP very high |
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 Preferred Practice Pattern on Primary Angle-Closure Disease — Link