A 58-year-old woman presents to the emergency department with sudden onset of severe left eye pain, blurred vision, and nausea for the past 3 hours. She reports seeing halos around lights. On examination, the left eye shows conjunctival injection, a mid-dilated and non-reactive pupil, corneal edema, and intraocular pressure of 58 mmHg. Gonioscopy reveals a closed angle. What is the immediate management priority?

Explanation

## Acute Angle-Closure Glaucoma: Emergency Management ### Clinical Presentation Recognition **Key Point:** The triad of severe eye pain, blurred vision with halos, and a mid-dilated non-reactive pupil with corneal edema and markedly elevated IOP (>40 mmHg) is pathognomonic for acute angle-closure glaucoma. ### Immediate Management Strategy **High-Yield:** The goal in acute angle-closure is rapid IOP reduction *before* definitive laser treatment to prevent irreversible optic nerve and corneal damage. ```mermaid flowchart TD A[Acute Angle-Closure Glaucoma]:::outcome --> B[Reduce IOP Medically]:::action B --> C[Topical agents: Timolol, Dorzolamide]:::action B --> D[Systemic: IV Acetazolamide, IV Mannitol]:::action C --> E[Clear cornea for gonioscopy]:::outcome D --> E E --> F[Perform Laser Peripheral Iridotomy]:::action F --> G[Definitive treatment achieved]:::outcome H[Contraindicated in acute phase]:::urgent I[Anterior chamber paracentesis] --> H J[Trabeculectomy] --> H ``` ### Medical Management (First-Line) | Agent | Type | Mechanism | Dosing | | --- | --- | --- | --- | | Timolol 0.5% | Topical beta-blocker | ↓ aqueous production | 2 drops, 15 min apart | | Dorzolamide 1% | Topical carbonic anhydrase inhibitor | ↓ aqueous production | 2 drops, 15 min apart | | IV Acetazolamide | Systemic CAI | ↓ aqueous production, ↓ vitreous volume | 500 mg IV | | IV Mannitol | Osmotic agent | ↓ vitreous volume, pulls lens-iris diaphragm back | 1 g/kg IV | **Clinical Pearl:** Prostaglandin analogues (latanoprost, travoprost) are CONTRAINDICATED in acute angle-closure because they can worsen inflammation and increase uveoscleral outflow resistance. ### Definitive Treatment: Laser Peripheral Iridotomy **Key Point:** Once corneal clarity is restored (usually within 30–60 minutes of medical therapy), YAG laser peripheral iridotomy is performed to create a patent communication between the posterior and anterior chambers, relieving the pupillary block mechanism. ### Why NOT Other Options - **Anterior chamber paracentesis:** Reserved only for cases with corneal opacification so dense that laser cannot be performed; not first-line. - **Cataract surgery:** Definitive in phacomorphic glaucoma, not primary angle-closure; may be considered later if cataract is the underlying anatomical cause. - **Trabeculectomy:** Indicated only if laser iridotomy fails; not first-line in acute presentation. **Warning:** Attempting laser treatment before IOP reduction risks further corneal damage and treatment failure due to poor visualization. [cite:Khurana 6e Ch 12]