eMedicine Specialties > Ophthalmology > Intraocular Pressure

Glaucoma, Angle Closure, Acute: Treatment & Medication

Author: Robert J Noecker, MD, MBA, Associate Professor, Department of Ophthalmology, University of Pittsburgh School of Medicine; Director, Glaucoma Service, Vice Chair, Department of Ophthalmology, University of Pittsburgh Medical Center Eye Center
Coauthor(s): Malik Y Kahook, MD, Clinical Instructor of Ophthalmology, Fellow in Glaucoma, Department of Ophthalmology, University of Pittsburgh Medical Center
Contributor Information and Disclosures

Updated: Jun 18, 2009

Treatment

Medical Care

Definitive treatment of ACG is laser iridotomy, or, if the iris cannot be accessed by laser, surgical iridectomy. Medical treatment is intended to prepare the patient for laser iridotomy. The cornea should be cleared with osmotic agents, the pupil should be constricted, and IOP should be lowered to prevent acute damage to the optic nerve.

Surgical Care

  • Laser iridotomy: Treatment of choice for pupillary-block ACG is laser iridotomy. Iridotomy with an argon or Nd:YAG laser creates an opening in the iris through which aqueous humor trapped in the posterior chamber can reach the anterior chamber and trabecular meshwork. As aqueous flows into the anterior chamber through the iris defect, pressure behind the iris falls, allowing the iris to recede toward its normal position. This procedure opens the anterior chamber angle and relieves the blockade of trabecular meshwork. If the cornea is extremely cloudy or the patient cannot cooperate, incisional peripheral iridectomy may be performed instead of a laser procedure.
  • Laser gonioplasty: Laser may be used to create stromal burns in the peripheral iris. As the iris contracts, the anterior chamber angle deepens. Use laser gonioplasty as treatment of ACG due to plateau iris and nanophthalmos, or use it as a temporary measure to open the angle until laser iridotomy can be performed.

Medication

The medical therapy for acute ACG is directed toward preparing the patient for laser or incisional iridotomy, which will create passage through the iris from the posterior to anterior chamber and will break an acute attack. IOP must be returned to normal, and the cornea must be cleared before a definitive procedure can be undertaken. In acute ACG, several drugs from different classes are used simultaneously to accelerate and maximize their pressure-lowering effects.

Alpha-adrenergic agonists

Topical adrenergic agonists, or sympathomimetics, decrease aqueous production and reduce resistance to aqueous outflow. Adverse effects include dry mouth and allergenicity.


Brimonidine (Alphagan)

Selective alpha2-receptor that reduces aqueous humor formation and possibly increases uveoscleral outflow.

Adult

1 gtt OU bid

Pediatric

<2 years: Not recommended; severe mental, cardiovascular, and pulmonary depression have been reported in pediatric patients
>2 years: Not established

Coadministration with topical beta-blockers may further decrease IOP; tricyclic antidepressants may decrease effects of brimonidine; CNS depressants such as barbiturates, opiates, and sedatives may potentiate effects of brimonidine

Documented hypersensitivity; patients receiving MAOIs

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in cardiovascular disease, depression, cerebral or coronary insufficiency, orthostatic hypotension, Raynaud syndrome


Apraclonidine (Iopidine) 0.5%, 1%

Potent alpha-adrenergic agent selective for alpha2-receptors with minimal cross-reactivity to alpha1-receptors. Reduces IOP whether or not accompanied by glaucoma. Selective alpha-adrenergic agonist without significant local anesthetic activity. Has minimal cardiovascular effect.

Adult

1 gtt tid in affected eye(s)

Pediatric

Not established

Monitor pulse and BP frequently when giving cardiovascular drugs; not for use concurrently with MAOIs

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in coronary insufficiency, chronic renal failure, recent myocardial infarction, cerebrovascular disease, Raynaud disease, thromboangiitis obliterans, and in patients who are depressed

Beta-blockers

Topical beta-adrenergic receptor antagonists decrease aqueous humor production by the ciliary body. Adverse effects of the beta-blockers are due to systemic absorption of the drug and include decreased cardiac output and bronchial constriction. In susceptible patients, this may cause bronchospasm, bradycardia, heart block, or hypotension. Pulse rate and blood pressure should be monitored in patients receiving topical beta-blocker therapy, and punctal occlusion may be performed after administration of the drops.


Levobunolol (Betagan, AKBeta) 0.25%, 0.5%

Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production

Adult

1 gtt bid in affected eye(s)

Pediatric

Not established

May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)

Documented hypersensitivity; bronchial asthma; severe chronic obstructive pulmonary disease; sinus bradycardia; second- and third-degree AV block; overt cardiac failure; cardiogenic shock

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Beta-blockade may potentiate muscle weakness that is consistent with certain myasthenic symptoms (eg, diplopia, ptosis, generalized weakness); product may have sulfites, which may cause allergic-type reactions in certain susceptible persons


Betaxolol (Betoptic) 0.25%, 0.5%

Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor.

Adult

1-2 gtt in affected eye(s) bid; consider concomitant therapy if IOP is not at satisfactory level

Pediatric

Not established

May have additive systemic effects if patient is already on systemic beta-blockers

Documented hypersensitivity; bronchial asthma; severe chronic obstructive pulmonary disease; sinus bradycardia; second- and third-degree AV block; overt cardiac failure; cardiogenic shock

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Beta-blockade may potentiate muscle weakness consistent with myasthenic symptoms; product may have sulfites, which may cause hypersensitivity reactions in susceptible persons


Timolol maleate (Timoptic, Timoptic XE) 0.25%, 0.5%

May reduce elevated and normal IOP, with or without glaucoma, by reducing production of aqueous humor.

Adult

1 gtt of 0.25% or 0.5% in affected eye(s) bid; if IOP is maintained at satisfactory levels, change dosage to 1 gtt in affected eye(s) qd
If clinical response not adequate, change dosage to 1 gtt of 0.5% solution in affected eye(s) bid; if IOP is still not at satisfactory level, consider concomitant therapy

Pediatric

Administer as in adults

May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)

Documented hypersensitivity; bronchial asthma; sinus bradycardia; second- and third-degree AV block; severe chronic obstructive pulmonary disease; overt cardiac failure; cardiogenic shock

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Product may have sulfites, which may cause allergic-type reactions in susceptible patients

Miotic agents (parasympathomimetics)

Contract ciliary muscle, tightening the trabecular meshwork and allowing increased outflow of the aqueous. Miosis results from action of these drugs on pupillary sphincter. Adverse effects include brow ache, induced myopia, and decreased vision in low light.


Pilocarpine (Pilocar, Pilagan) 1%, 2%, 4%, 5%, 6%, 8%, 10%, gel 4%

A naturally occurring alkaloid, pilocarpine mimics muscarinic effects of acetylcholine at postganglionic parasympathetic nerves. Directly stimulates cholinergic receptors in the eye, decreasing resistance to aqueous humor outflow.
Instillation frequency and concentration are determined by patient's response. Individuals with heavily pigmented irides may require higher strengths. If other glaucoma medication also is being used, at bedtime, use gtt at least 5 min before gel. May use alone, or in combination with other miotics, beta-adrenergic blocking agents, epinephrine, carbonic anhydrase inhibitors, or hyperosmotic agents to decrease IOP.

Adult

1 or 2 gtt tid/qid

Pediatric

Not established

May be ineffective when used concomitantly with nonsteroidal anti-inflammatory agents

Documented hypersensitivity; acute inflammatory disease of anterior chamber

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Warn patients that pilocarpine causes pupillary constriction and may cause decreased vision in presence of cataract; also may cause aching pain in eye or artificial myopia because of increased accommodation; caution in acute cardiac failure, peptic ulcer, hyperthyroidism, GI spasm, bronchial asthma, Parkinson disease, recent MI, urinary tract obstruction, and hypertension or hypotension

Prostaglandin analogs

Increase uveoscleral outflow of the aqueous. One mechanism of action may be through induction of metalloproteinases in ciliary body, which breaks down extracellular matrix, thereby reducing resistance to outflow through ciliary body.


Latanoprost (Xalatan) 0.005%

Decreases IOP by increasing outflow of aqueous humor.

Adult

1 gtt (1.5 mcg) in affected eye qd in evening; higher frequency administrations may decrease effectiveness

Pediatric

Not established

Coadministration with eye drops, containing the preservative thimerosal, may reduce effects (administer at intervals of 5 min between applications)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not administer while wearing contact lenses; may increase brown pigment in iris and change eye color gradually (unknown effect)

Carbonic anhydrase inhibitors

Reduce secretion of aqueous humor by inhibiting carbonic anhydrase in ciliary body. In acute ACG, may be given systemically but are used topically in patients with refractory open-angle glaucoma. Topical formulations are less effective, and their duration of action is shorter than many other classes of drugs. Adverse effects of topical carbonic anhydrase inhibitors are relatively rare, but they include superficial punctate keratitis, acidosis, paresthesias, nausea, depression, and lassitude.


Acetazolamide (Diamox)

Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute ACG when delay of surgery desired to lower IOP.

Adult

250 mg to 1 g PO/IV q24h

Pediatric

Not established

Can decrease therapeutic levels of lithium and alter excretion of drugs (amphetamines, quinidine, phenobarbital, salicylates) by alkalinizing urine

Documented hypersensitivity; hepatic disease, severe renal disease, adrenocortical insufficiency, or severe pulmonary obstruction; low blood sodium or potassium, severe kidney and liver dysfunction, adrenal failure, and hyperchloremic acidosis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor patients for adverse reactions to sulfonamides; may experience paresthesias of extremities, tinnitus, taste alterations, or gastrointestinal distress


Methazolamide (GlaucTabs, Neptazane)

Reduces aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP.

Adult

50-100 mg PO bid/tid

Pediatric

Not established

Caution in patients on high-dose aspirin or steroid therapy; may increase toxicity of salicylate, digoxin; coadministration with other diuretics may induce hypokalemia; decreases effects of lithium and alter excretion of other drugs by alkalinizing urine

Documented hypersensitivity; renal impairment

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in respiratory acidosis and diabetes mellitus; impairs mental alertness and/or physical coordination; hematuria, glycosuria, polyuria, hepatic insufficiency, bone marrow suppression, thrombocytopenia/purpura, agranulocytosis, urticaria, pruritus, and rash may occur


Dorzolamide HCl (Trusopt) 2%

Used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one ophthalmic drug is being used, administer the drugs at least 10 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increases renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.

Adult

1 gtt in affected eye(s) tid

Pediatric

Not established

Coadministration with high-dose salicylate therapy may increase toxicity; may have additive systemic effects if patient is already on oral CA inhibitors

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with long-term administration of dorzolamide (discontinue therapy and evaluate patient before restarting therapy)


Brinzolamide (Azopt) 1%

Catalyzes reversible reaction involving hydration of carbon dioxide and dehydration of carbonic acid. May use concomitantly with other topical ophthalmic drug products to lower IOP. If more than one topical ophthalmic drug is being used, administer drugs at least 10 min apart.

Adult

1 gtt in affected eye(s) tid

Pediatric

Not established

May have additive systemic effects if patient is already on oral CA inhibitors

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with long-term administration of dorzolamide (discontinue therapy and evaluate patient before restarting therapy)


Dorzolamide HCl/ timolol maleate (Cosopt)

CA inhibitor that may decrease aqueous humor secretion, causing a decrease in IOP. Presumably slows bicarbonate ion formation with subsequent reduction in sodium and fluid transport.
Timolol is a nonselective beta-adrenergic receptor blocker that decreases IOP by decreasing aqueous humor secretion and may slightly increase outflow facility. Both agents administered together bid may result in additional IOP reduction compared with either component administered alone, but reduction is not as much as when dorzolamide tid and timolol bid are administered concomitantly.

Adult

1 gtt into affected eye(s) bid; if more than one topical ophthalmic drug is used, administer at least 10 min apart

Pediatric

Not established

Coadministration with high-dose salicylate therapy may increase toxicity; may have additive systemic effects if patient is already on oral CA inhibitors

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with long-term administration of dorzolamide (discontinue therapy and evaluate patient before restarting therapy); product may have sulfites, which may cause allergic-type reactions in susceptible patients

More on Glaucoma, Angle Closure, Acute

Overview: Glaucoma, Angle Closure, Acute
Differential Diagnoses & Workup: Glaucoma, Angle Closure, Acute
Treatment & Medication: Glaucoma, Angle Closure, Acute
Follow-up: Glaucoma, Angle Closure, Acute
References
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References

  1. Cantor L, et al. Glaucoma. In: Basic and Clinical Science Course. Section 10. 1996-7.

  2. Epstein DL, Allingham RR, Schuman JS. Chandler and Grant's Glaucoma. 4th ed. 1997.

  3. Hitchings RA. Glaucoma: current thinking. Br J Hosp Med. Mar 20-Apr 2 1996;55(6):312-4. [Medline].

  4. Lai JS, Tham CC, Chan JC. The clinical outcomes of cataract extraction by phacoemulsification in eyes with primary angle-closure glaucoma (PACG) and co-existing cataract: a prospective case series. J Glaucoma. Feb 2006;15(1):47-52. [Medline].

  5. Liesegang TJ. Glaucoma: changing concepts and future directions. Mayo Clinic Proceedings. 1996;71:689-694.

  6. Nolan W. Anterior segment imaging: ultrasound biomicroscopy and anterior segment optical coherence tomography. Curr Opin Ophthalmol. Mar 2008;19(2):115-21. [Medline].

  7. Shields MB. Textbook of Glaucoma. 4th ed. 1998.

  8. Sihota R, Dada T, Gupta R, et al. Ultrasound biomicroscopy in the subtypes of primary angle closure glaucoma. J Glaucoma. Oct 2005;14(5):387-91. [Medline].

  9. Xu L, Cao WF, Wang YX, Chen CX, Jonas JB. Anterior chamber depth and chamber angle and their associations with ocular and general parameters: the Beijing Eye Study. Am J Ophthalmol. May 2008;145(5):929-36. [Medline].

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Further Reading

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Keywords

acute angle glaucoma, acute angle-closure glaucoma, acute angle closure glaucoma, angle closure glaucoma, angle-closure glaucoma, ACG, narrow-angle glaucoma, narrow angle glaucoma, narrow angles, vision loss, visual deficit

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Contributor Information and Disclosures

Author

Robert J Noecker, MD, MBA, Associate Professor, Department of Ophthalmology, University of Pittsburgh School of Medicine; Director, Glaucoma Service, Vice Chair, Department of Ophthalmology, University of Pittsburgh Medical Center Eye Center
Robert J Noecker, MD, MBA is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, American Medical Association, American Society of Cataract and Refractive Surgery, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Malik Y Kahook, MD, Clinical Instructor of Ophthalmology, Fellow in Glaucoma, Department of Ophthalmology, University of Pittsburgh Medical Center
Malik Y Kahook, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, and Colorado Medical Society
Disclosure: Alcon Consulting fee Consulting

Medical Editor

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Martin B Wax, MD, Clinical Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Ophthalmology Research and Development, Head, Ophthalmology Discovery Research, Alcon Labs, Inc
Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Society for Neuroscience
Disclosure: Alcon Labs Salary Employment

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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