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Emergency management:
angle-closure glaucoma
Desirée Murray Acute angle-closure glaucoma is an ophthalmic
Lecturer in
emergency as it can lead to irreversible blindness if
Department of not identified and treated immediately.
Clinical Surgical
Sciences, The
University of the
Presentation be considered as a

West Indies, Mount The patient may complain of a painful red eye, definitive treatment
Hope, Trinidad and headache, blurred vision, haloes, nausea, vomiting for patients with
Tobago, West Indies. and abdominal pain (sometimes misdiagnosed as co-existing cataract
gastroenteritis). Precipitating factors include dim and presenting IOP Figure 2 Peripheral iridotomy
light and certain drugs (e.g., bronchodilators, cough >55   mmHg.1 After
mixtures, cold and flu medication, antidepressants, the acute attack is successfully treated with medication,
antihistamines and anticonvulsants). the cataract is replaced by a thinner artificial lens
implant, thereby relieving the pupil block.
Examination findings include conjunctival injection In other patients, the basis of treatment is an iridotomy:
around the cornea (red eye), mid-dilated nonreactive the creation of a hole in the peripheral iris (Figure 2),
pupil, corneal haze, diminished red reflex and a hard either surgically or using a laser. This bypasses the pupil
Figure 1 Clinical globe, with intraocular pressure (IOP) of between 50 block and reestablishes flow from the posterior to the
findings in acute anterior chamber. If the other eye is at risk, iridotomy is
and 80 mmHg. Central retinal artery and central retinal
angle-closure performed in both eyes.
vein occlusion may also occur.
Protocol How to prepare for this emergency
Red eye Treatment goal: immediate Put together an acute angle-closure glaucoma
lowering of IOP and alleviation of emergency kit containing all the medication (see
inflammation, pain, nausea. panel),2 needles and syringes that may be needed.
Include a copy of the treatment protocol and the
1. Relieve pupil block. Ask the
contact details of the nearest ophthalmologist. This
patient to lie down on her or
will ensure that you and your team are prepared.

his back. This improves the lens

Check expiry dates regularly as this sight-threatening
position (it will be more posterior)
emergency is uncommon. The storage container should
and thereby relieves pupil block.
Corneal be clearly labelled and kept in the emergency room for
haze 2. Lower IOP. Give acetazolamide easy access. Every team member must know where the
pupil 500  mg, preferably intravenously kit is stored and be familiar with its contents.
or orally, if intravenous is not
available or if the patient is not nauseated. Instil topical Emergency kit: medication
glaucoma medications (beta blockers, alpha agonists
and prostaglandin analogues). • Intravenous acetazolamide 500 mg, provided
as a sterile powder requiring reconstitution (or
3. Reduce pain by giving analgesics and reduce
oral acetazolamide if intravenous is unavailable)
inflammation by instilling topical steroids.
• Hyperosmotic agents
4. Reduce nausea and vomiting. Give anti-emetics. −− Oral glycerol 1.0–1.5 g/kg (contraindicated in
1 Lam DSC, Leung DYL,
After approximately 1 hour, the decrease in IOP should patients with diabetes)
Tham CCY, Li FCH,
Kwong YYY, Chiu TYH, improve blood supply to the iris and make it more −− Oral isosorbide 1.5–2.0 g/kg (as an alternative
Fan DSP. Randomized responsive to pilocarpine. in patients with diabetes)
trial of early −− Intravenous mannitol 1–2 g/kg (500 ml of 20%)
phacoemulsification Instil pilocarpine (2% or 4% eye drops) in two doses,
• Topical steroids (prednisolone)
versus peripheral spaced 15 minutes apart. If IOP remains dangerously
iridotomy to prevent • Topical glaucoma drugs
elevated after the second dose of pilocarpine, consider
intraocular pressure −− Beta blocker (timolol)
giving hyperosmotic agents such as glycerol, isosorbide or
rise after acute −− Alpha 2 agonist (brimonidine, apraclonidine)
primary angle closure. mannitol. Extreme caution is advised in patients with
−− Prostaglandin analogue (latanoprost,
Ophthalmology cardiovascular conditions and renal impairment,
travoprost, bimatoprost)
as the side effects can be life-threatening. Glycerol
2 IAPB Essential List for
• Topical pilocarpine 2% or 4%
is contraindicated in patients with diabetes.
Glaucoma. Available at • Non-oral analgesics (or oral if other routes are
https://iapb. Referral and treatment not available)
Once the patient is stabilised, refer her or him to an • Non-oral anti-emetics (or oral if other routes are
not available)
uploads/2017/04/ ophthalmologist immediately.
IAPB_EL_for_ • Contact details of the nearest ophthalmologist
Glaucoma_2017.pdf Because the lens plays a major role in the mechanism (on-site or off-site) for emergency referral.
(accessed 10 June, 2018). of acute angle-closure glaucoma, cataract extraction can