Acute Angle-Closure

Glaucoma Treatment &

Management
The patient should be brought to the hospital in an expeditious
manner to have intraocular pressure (IOP) reduced. The patient
should remain in the supine position as long as possible. The
urge to wear eye patches, covers, or blindfolds should be
resisted. By maintaining the conditions that cause pupillary
dilation, these articles help perpetuate the attack. Their potential
negative effects outweigh any presumed benefit.
The treatment of acute angle-closure glaucoma (AACG)
consists of IOP reduction, suppression of inflammation, and the
reversal of angle closure. Once diagnosed, the initial
intervention includes acetazolamide, a topical beta-blocker, and
a topical steroid.
Acetazolamide should be given as a stat dose of 500 mg IV
followed by 500 mg PO. A dose of a topical beta-blocker (ie,
carteolol, timolol) will also aid in lowering IOP. Studies have
not conclusively demonstrated the superior neuronal or visual
field protectiveness of one beta-blocker over another. Both beta-
blockers and acetazolamide are thought to decrease aqueous
humor production and to enhance opening of the angle. An
alpha-agonist can be added for a further decrease in IOP.
Inflammation is an important part of the pathophysiology and
presenting symptomology. Topical steroids decrease the
inflammatory reaction and reduce optic nerve damage. The
current recommendation is for 1-2 doses of topical steroids.
Addressing the extraocular manifestations of the disease is
critical. This includes analgesics for pain and antiemetics for
nausea and vomiting, which can drastically increase IOP beyond
its already elevated level. Placing the patient in the supine
position may aid in comfort and reduce IOP. It is also believed
that, while supine, the lens falls away from the iris decreasing
pupillary block.
After the initial intervention, the patient should be reassessed.
Reassessment includes evaluating IOP, evaluating adjunct
drops, and considering the need for further intervention, such as
osmotic agents and immediate iridotomy.
Approximately 1 hour after beginning treatment, pilocarpine, a
miotic that leads to opening of the angle, should be administered
every 15 minutes for 2 doses. In the initial attack, the elevated
pressure in the anterior chamber causes a pressure-induced
ischemic paralysis of the iris. At this time, pilocarpine would be
ineffective. During the second evaluation, the initial agents have
decreased the elevated IOP and hopefully have reduced the
ischemic paralysis so pilocarpine becomes beneficial in
relieving pupillary block.
Pilocarpine must be used with caution. Theoretical concerns
exist about its mechanism of action. By constricting the ciliary
muscle, it has been shown to increase the axial thickness of the
lens and to induce anterior lens movement. This could result in
reducing the depth of the anterior chamber and worsening the
clinical situation in a paradoxical reaction. Despite this,
pilocarpine is recommended to be used as an additional agent.
[
17]
No standard rate of reduction for IOP exists; however, Choong
et el identified a satisfactory reduction as IOP less than 35 mm
Hg or a reduction greater than 25% of presenting IOP. [16] If the
IOP is not reduced 30 minutes after the second dose of
pilocarpine, an osmotic agent must be considered. An oral agent
like glycerol can be administered in nondiabetics. In diabetics,
oral isosorbide is used to avoid the risk of hyperglycemia
associated with glycerol. Patients who are unable to tolerate oral
intake or do not experience a decrease in IOP despite oral
therapy are candidates for IV mannitol.
Hyperosmotic agents are useful for several reasons. They reduce
vitreous volume, which, in turn, decreases IOP. The decreased
IOP reverses iris ischemia and improves its responsiveness to
pilocarpine and other drugs. Osmotic agents cause an osmotic
diuresis and total body fluid reduction. They should be
administered with caution in cardiovascular and renal patients.
Choong et el demonstrated that 44% of patients required the
addition of an osmotic agent to decrease IOP. [18] Repeat doses
may be necessary if no effect is seen and if tolerated by the
patient.
When medical therapy proves to be ineffective, corneal
indentation (CI) can be used as a temporizing measure to reduce
IOP until definitive treatment is available. As the cornea is
indented, aqueous humor is displaced to the periphery of the
anterior chamber, which serves to temporarily open the angle.
This leads to immediate reduction of IOP and occasionally may
completely abort the attack. After applying topical anesthetic,
any smooth instrument can be used to perform this procedure,
including a gonioprism (ideal, if available), or a cotton-tipped
applicator. Obviously, a concern with performing CI is the
possibility for damage to the corneal epithelium, which may
complicate the patients course. [19]
Laser peripheral iridotomy (LPI), performed 24-48 hours after
IOP is controlled, is considered the definitive treatment for
AACG. Furthermore, LPI may be offered prophylactically to
individuals anatomically predisposed to AACG if identified
before the first acute attack. While LPI is the current definitive
treatment, evidence suggests that argon laser peripheral
iridoplasty (ALPI) and anterior chamber paracentesis (ACP)
may have increasing roles in the management of AACG.
In ALPI, burns are made in the peripheral iris resulting in iris
contraction and opening of the angle. Some studies suggest
ALPI causes a more immediate decrease in IOP, resulting in
better outcomes with fewer side effects than systemic therapy.
20 However, a recent randomized-controlled trial comparing
[ ]

LPI plus ALPI compared with ALI alone failed to show

improved outcomes with ALPI as an adjunctive therapy. [21]
Systemic therapy must still be used with ACP, but ACP appears
to instantaneously relieve symptoms.
An additional alternative is lens extraction. Although its role in
AACG has not been completely established, it has been proven
to effectively reduce IOP without the need for medication
postoperatively. Furthermore, it offers a therapeutic advantage
for individuals with coexisting cataracts. [22]
The choice of which therapy to use will be made by an
ophthalmologist who will evaluate all patients via gonioscopy
with complete inspection of the angle. At institutions where
ophthalmologic consultation is immediately available, initial
treatment should be performed in conjunction with the
specialist.
If ophthalmologic consultation is not immediately available, the
emergency department physician must begin pharmacologic
therapy as described above. After appropriate therapy aimed at
IOP reduction, ophthalmologic evaluation must be ensured by
transferring the patient, if necessary. If the IOP is unchanged or
increased, with appropriate pharmacologic therapy, the attack
most likely will terminate only with LPI. Because outcome is
adversely affected by the duration of symptoms, expeditious
evaluation by a specialist is required. Ocular massage through a
closed eyelid may be performed while waiting for
ophthalmology if no other treatment reduces IOP.

http://emedicine.medscape.com/article/798811-treatment Acute Angle-

Closure Glaucoma Treatment & Management The patient should be brought
to the hospital in an expeditious manner to have intraocular pr