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AcuteAngleClosureGlaucomaTreatment&Management:PrehospitalCare,EmergencyDepartmentCare,Consultations

AcuteAngleClosureGlaucomaTreatment&
Management
Author:JosephFreedman,MDChiefEditor:StevenCDronen,MD,FAAEMmore...
Updated:Oct27,2015

PrehospitalCare
Thepatientshouldbebroughttothehospitalinanexpeditiousmannertohave
intraocularpressure(IOP)reduced.Thepatientshouldremaininthesupineposition
aslongaspossible.Theurgetoweareyepatches,covers,orblindfoldsshouldbe
resisted.Bymaintainingtheconditionsthatcausepupillarydilation,thesearticles
helpperpetuatetheattack.Theirpotentialnegativeeffectsoutweighanycosmetic
benefit.

EmergencyDepartmentCare
Thetreatmentofacuteangleclosureglaucoma(AACG)consistsofIOPreduction,
suppressionofinflammation,andthereversalofangleclosure.Oncediagnosed,
theinitialinterventionincludesacetazolamide,atopicalbetablocker,andatopical
steroid.
Acetazolamideshouldbegivenasastatdoseof500mgIVfollowedby500mg
PO.Adoseofatopicalbetablocker(ie,carteolol,timolol)willalsoaidinlowering
IOP.Studieshavenotconclusivelydemonstratedthesuperiorneuronalorvisual
fieldprotectivenessofonebetablockeroveranother.Bothbetablockersand
acetazolamidearethoughttodecreaseaqueoushumorproductionandtoenhance
openingoftheangle.AnalphaagonistcanbeaddedforafurtherdecreaseinIOP.
Inflammationisanimportantpartofthepathophysiologyandpresenting
symptomology.Topicalsteroidsdecreasetheinflammatoryreactionandreduce
opticnervedamage.Thecurrentrecommendationisfor12dosesoftopical
steroids.
Addressingtheextraocularmanifestationsofthediseaseiscritical.Thisincludes
analgesicsforpainandantiemeticsfornauseaandvomiting,whichcandrastically
increaseIOPbeyonditsalreadyelevatedlevel.Placingthepatientinthesupine
positionmayaidincomfortandreduceIOP.Itisalsobelievedthat,whilesupine,
thelensfallsawayfromtheirisdecreasingpupillaryblock.
Aftertheinitialintervention,thepatientshouldbereassessed.Reassessment
includesevaluatingIOP,evaluatingadjunctdrops,andconsideringtheneedfor
furtherintervention,suchasosmoticagentsandimmediateiridotomy.
Approximately1hourafterbeginningtreatment,pilocarpine,amioticthatleadsto
openingoftheangle,shouldbeadministeredevery15minutesfor2doses.Inthe
initialattack,theelevatedpressureintheanteriorchambercausesapressure
inducedischemicparalysisoftheiris.Atthistime,pilocarpinewouldbeineffective.
Duringthesecondevaluation,theinitialagentshavedecreasedtheelevatedIOP
andhopefullyhavereducedtheischemicparalysissopilocarpinebecomes
beneficialinrelievingpupillaryblock.
Pilocarpinemustbeusedwithcaution.Theoreticalconcernsexistaboutits
mechanismofaction.Byconstrictingtheciliarymuscle,ithasbeenshownto
increasetheaxialthicknessofthelensandtoinduceanteriorlensmovement.This
couldresultinreducingthedepthoftheanteriorchamberandworseningtheclinical
situationinaparadoxicalreaction.Despitethis,pilocarpineisrecommendedtobe
usedasanadditionalagent. [17]
NostandardrateofreductionforIOPexistshowever,Choongetelidentifieda
satisfactoryreductionasIOPlessthan35mmHgorareductiongreaterthan25%
ofpresentingIOP. [16]IftheIOPisnotreduced30minutesaftertheseconddoseof
pilocarpine,anosmoticagentmustbeconsidered.Anoralagentlikeglycerolcan
beadministeredinnondiabetics.Indiabetics,oralisosorbideisusedtoavoidthe
riskofhyperglycemiaassociatedwithglycerol.Patientswhoareunabletotolerate
oralintakeordonotexperienceadecreaseinIOPdespiteoraltherapyare
candidatesforIVmannitol.
Hyperosmoticagentsareusefulforseveralreasons.Theyreducevitreousvolume,
which,inturn,decreasesIOP.ThedecreasedIOPreversesirisischemiaand
improvesitsresponsivenesstopilocarpineandotherdrugs.Osmoticagentscause
anosmoticdiuresisandtotalbodyfluidreduction.Theyshouldnotbeadministered
incardiovascularandrenalpatients.Choongeteldemonstratedthat44%of
patientsrequiredtheadditionofanosmoticagenttodecreaseIOP. [18]Repeat
dosesmaybenecessaryifnoeffectisseenandiftoleratedbythepatient.
Whenmedicaltherapyprovestobeineffective,cornealindentation(CI)canbeused
asatemporizingmeasuretoreduceIOPuntildefinitivetreatmentisavailable.As

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AcuteAngleClosureGlaucomaTreatment&Management:PrehospitalCare,EmergencyDepartmentCare,Consultations

thecorneaisindented,aqueoushumorisdisplacedtotheperipheryoftheanterior
chamber,whichservestotemporarilyopentheangle.Thisleadstoimmediate
reductionofIOPandoccasionallymaycompletelyaborttheattack.Afterapplying
topicalanesthetic,anysmoothinstrumentcanbeusedtoperformthisprocedure,
includingagonioprism(ideal,ifavailable),oracottontippedapplicator.Obviously,
aconcernwithperformingCIisthepossibilityfordamagetothecornealepithelium,
whichmaycomplicatethepatientscourse. [19]
Laserperipheraliridotomy(LPI),performed2448hoursafterIOPiscontrolled,is
consideredthedefinitivetreatmentforAACG.Furthermore,LPImaybeoffered
prophylacticallytoindividualsanatomicallypredisposedtoAACGifidentifiedbefore
thefirstacuteattack.WhileLPIisthecurrentdefinitivetreatment,evidence
suggeststhatargonlaserperipheraliridoplasty(ALPI)andanteriorchamber
paracentesis(ACP)mayhaveincreasingrolesinthemanagementofAACG.
InALPI,burnsaremadeintheperipheralirisresultinginiriscontractionand
openingoftheangle.SomestudiessuggestALPIcausesamoreimmediate
decreaseinIOP,resultinginbetteroutcomeswithfewersideeffectsthansystemic
therapy. [20]However,arecentrandomizedcontrolledtrialcomparingLPIplusALPI
comparedwithALIalonefailedtoshowimprovedoutcomeswithALPIasan
adjunctivetherapy. [21]SystemictherapymuststillbeusedwithACP,butACP
appearstoinstantaneouslyrelievesymptoms.
Anadditionalalternativeislensextraction.AlthoughitsroleinAACGhasnotbeen
completelyestablished,ithasbeenproventoeffectivelyreduceIOPwithoutthe
needformedicationpostoperatively.Furthermore,itoffersatherapeuticadvantage
forindividualswithcoexistingcataracts. [22]
Thechoiceofwhichtherapytousewillbemadebyanophthalmologistwhowill
evaluateallpatientsviagonioscopywithcompleteinspectionoftheangle.At
institutionswhereanophthalmologistisimmediatelyavailableonstaff,initial
treatmentshouldbeperformedinconjunctionwiththespecialist.
Ifthereisadelayedintervalbetweentheinitialpresentationanddefinitive
ophthalmiccare,theemergencydepartmentphysicianshouldbegintreatmentas
describedabove.AfteranappropriatereductioninIOP,immediateophthalmic
evaluationmustbeensured.IftheIOPisunchangedorincreasedfromthetimeof
treatment,furthertreatmentshouldbediscontinuedandtheattackmostlikelywill
terminateonlywithLPI.Ocularmassagethroughaclosedeyelidmaybepreformed
whilewaitingforophthalmologyifnoothertreatmentreducesIOP.

Consultations
Ophthalmicconsultationshouldbeobtainedassoonaspossiblebecauseacute
angleclosureglaucomaisanophthalmicemergency.
Medication

ContributorInformationandDisclosures
Author
JosephFreedman,MDResidentPhysician,DepartmentofEmergencyMedicine,StateUniversityofNewYork
Downstate,King'sCountyHospitalCenter
JosephFreedman,MDisamemberofthefollowingmedicalsocieties:EmergencyMedicineResidents&#039
Association
Disclosure:Nothingtodisclose.
Coauthor(s)
RichardHSinert,DOProfessorofEmergencyMedicine,ClinicalAssistantProfessorofMedicine,Research
Director,StateUniversityofNewYorkCollegeofMedicineConsultingStaff,ViceChairinChargeofResearch,
DepartmentofEmergencyMedicine,KingsCountyHospitalCenter
RichardHSinert,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,Society
forAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AndrewAherne,MDResidentPhysician,DepartmentofEmergencyMedicine,KingsCountyHospitalCenter,
UniversityHospitalofBrooklyn
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
DouglasLavenburg,MDClinicalProfessor,DepartmentofEmergencyMedicine,ChristianaCareHealth
Systems
DouglasLavenburg,MDisamemberofthefollowingmedicalsocieties:AmericanSocietyofCataractand
RefractiveSurgery
Disclosure:Nothingtodisclose.

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ChiefEditor
StevenCDronen,MD,FAAEMChair,DepartmentofEmergencyMedicine,LeConteMedicalCenter
StevenCDronen,MD,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
Acknowledgements
AyimKDarkeh,MDAssistantProfessor,DepartmentofEmergencyMedicine,StateUniversityofNewYork
DownstateMedicalCenter
AyimKDarkehisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians,
EmergencyMedicineResidentsAssociation,NationalMedicalAssociation,andSocietyforAcademicEmergency
Medicine
Disclosure:Nothingtodisclose.
MichelleErvin,MDChair,DepartmentofEmergencyMedicine,HowardUniversityHospital
MichelleErvin,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,AmericanMedicalAssociation,NationalMedicalAssociation,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
MarkASilverberg,MD,MMB,FACEPAssistantProfessor,AssociateResidencyDirector,Departmentof
EmergencyMedicine,StateUniversityofNewYorkDownstateCollegeofMedicineConsultingStaff,
DepartmentofEmergencyMedicine,StatenIslandUniversityHospital,KingsCountyHospital,University
Hospital,StateUniversityofNewYorkDownstateMedicalCenter
MarkASilverberg,MD,MMB,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,AmericanMedicalAssociation,CouncilofEmergencyMedicineResidencyDirectors,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

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