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 4 hours. She reports seeing halos around lights. On examination, the left eye shows conjunctival injection, corneal edema, a mid-dilated fixed pupil, and intraocular pressure (IOP) of 58 mmHg. Gonioscopy cannot be performed due to corneal haze. What is the most appropriate immediate management?

Explanation

## Acute Angle-Closure Glaucoma: Emergency Management ### Clinical Presentation Recognition This patient presents with the classic triad of acute angle-closure glaucoma: - **Sudden severe eye pain** with blurred vision - **Halos** (due to corneal edema from elevated IOP) - **Mid-dilated fixed pupil** (from ischemic iris) - **Markedly elevated IOP** (>50 mmHg typical) - **Conjunctival injection** and corneal edema **Key Point:** Acute angle-closure is an ophthalmic emergency requiring rapid IOP reduction to prevent irreversible optic nerve damage and vision loss. ### Management Algorithm ```mermaid flowchart TD A[Acute Angle-Closure Glaucoma]:::outcome --> B[Reduce IOP Medically First]:::action B --> C[Topical: Beta-blocker + Carbonic anhydrase inhibitor]:::action B --> D[Systemic: IV acetazolamide + Oral osmotic agent]:::action B --> E[Avoid Pilocarpine Initially]:::urgent E --> F[Pilocarpine only after IOP controlled]:::action C --> G{IOP Reduced?}:::decision D --> G G -->|Yes| H[YAG Laser Peripheral Iridotomy]:::action G -->|No| I[Anterior Chamber Paracentesis]:::action H --> J[Definitive Treatment]:::outcome I --> K[Repeat Medical Therapy]:::action K --> H ``` ### Why Medical Management First? **High-Yield:** The corneal edema from acute IOP elevation prevents adequate visualization for gonioscopy and laser treatment. Medical therapy reduces IOP enough to clear the cornea (typically within 30–60 minutes), allowing subsequent definitive laser therapy. **Drugs and Rationale:** | Drug | Mechanism | Timing | | --- | --- | --- | | Topical beta-blocker (timolol) | Decreases aqueous production | Immediate | | Topical CAI (dorzolamide/brinzolamide) | Decreases aqueous production | Immediate | | IV acetazolamide 500 mg | Systemic aqueous suppression | Within 15 min | | Oral osmotic (glycerol 50% or IV mannitol) | Shrinks vitreous volume, deepens AC | Within 30 min | | Topical pilocarpine 2% | Miosis to pull lens back (only after IOP <40 mmHg) | After IOP controlled | **Clinical Pearl:** Pilocarpine is avoided initially because in acute angle-closure, the angle is already closed by the iris-lens diaphragm pushed forward. Pilocarpine causes further iris thickening and anterior displacement, worsening angle closure and IOP. It is used only after IOP is controlled and the angle begins to open. ### Definitive Treatment Once IOP is reduced and cornea clears, **YAG laser peripheral iridotomy** is performed to create a communication between posterior and anterior chambers, equalizing pressure and pulling the iris away from the angle. **Warning:** Do NOT attempt laser while cornea is edematous — the beam cannot penetrate and treatment will fail. ### Special Consideration: Anterior Chamber Paracentesis Paracentesis is a **rescue procedure** reserved for cases where medical therapy fails to reduce IOP sufficiently to allow laser treatment (e.g., IOP remains >40 mmHg after 30–60 minutes of maximal medical therapy). It is not the first-line immediate intervention. [cite:Khurana 6e Ch 11]