Medscape is available in 5 Language Editions – Choose your Edition here.


Acute Angle-Closure Glaucoma Treatment & Management

  • Author: Joseph Freedman, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
Updated: Oct 27, 2015

Prehospital Care

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 cosmetic benefit.


Emergency Department Care

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 not be administered 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 patient’s 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 an ophthalmologist is immediately available on staff, initial treatment should be performed in conjunction with the specialist.

If there is a delayed interval between the initial presentation and definitive ophthalmic care, the emergency department physician should begin treatment as described above. After an appropriate reduction in IOP, immediate ophthalmic evaluation must be ensured. If the IOP is unchanged or increased from the time of treatment, further treatment should be discontinued and the attack most likely will terminate only with LPI. Ocular massage through a closed eyelid may be preformed while waiting for ophthalmology if no other treatment reduces IOP.



Ophthalmic consultation should be obtained as soon as possible because acute-angle closure glaucoma is an ophthalmic emergency.

Contributor Information and Disclosures

Joseph Freedman, MD Resident Physician, Department of Emergency Medicine, State University of New York Downstate, King's County Hospital Center

Joseph Freedman, MD is a member of the following medical societies: Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.


Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrew Aherne, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, University Hospital of Brooklyn

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas Lavenburg, MD Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Ayim K Darkeh, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center

Ayim K Darkeh is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

  1. Berkoff DJ, Sanchez LD. An uncommon presentation of acute angle closure glaucoma. J Emerg Med. 2005 Jul. 29(1):43-4. [Medline].

  2. Yip LW, Aquino MC, Chew PT. Measurement of anterior lens growth after acute primary angle-closure glaucoma. Can J Ophthalmol. 2007 Apr. 42(2):321-2. [Medline].

  3. Wang BS, Narayanaswamy A, Amerasinghe N, Zheng C, He M, Chan YH, et al. Increased iris thickness and association with primary angle closure glaucoma. Br J Ophthalmol. 2010 Jun 7. [Medline].

  4. Cronemberger S, Calixto N, de Andrade AO, Mérula RV. New considerations on pupillary block mechanism. Arq Bras Oftalmol. 2010 Feb. 73(1):9-15. [Medline].

  5. Ang LP, Ang LP. Current understanding of the treatment and outcome of acute primary angle-closure glaucoma: an Asian perspective. Ann Acad Med Singapore. 2008 Mar. 37(3):210-5. [Medline].

  6. He M, Foster PJ, Ge J, Huang W, Zheng Y, Friedman DS. Prevalence and clinical characteristics of glaucoma in adult Chinese: a population-based study in Liwan District, Guangzhou. Invest Ophthalmol Vis Sci. 2006 Jul. 47(7):2782-8. [Medline].

  7. Vijaya L, George R, Arvind H, Baskaran M, Paul PG, Ramesh SV. Prevalence of angle-closure disease in a rural southern Indian population. Arch Ophthalmol. 2006 Mar. 124(3):403-9. [Medline].

  8. Rahim SA, Sahlas DJ, Shadowitz S. Blinded by pressure and pain. Lancet. 2005 Jun 25-Jul 1. 365(9478):2244. [Medline].

  9. Cholongitas E, Pipili C, Dasenaki M. Acute angle closure glaucoma presented with nausea and epigastric pain. Dig Dis Sci. 2008 May. 53(5):1430-1. [Medline].

  10. Croos R, Thirumalai S, Hassan S, Davis Jda R. Citalopram associated with acute angle-closure glaucoma: case report. BMC Ophthalmol. 2005 Oct 4. 5:23. [Medline]. [Full Text].

  11. Natesh S, Rajashekhara SK, Rao AS, Shetty B. Topiramate-induced angle closure with acute myopia, macular striae. Oman J Ophthalmol. 2010 Jan. 3(1):26-8. [Medline]. [Full Text].

  12. Subak-Sharpe I, Low S, Nolan W, Foster PJ. Pharmacological and environmental factors in primary angle-closure glaucoma. Br Med Bull. 2010. 93:125-43. [Medline].

  13. Etminan M, Maberley D, Mikelberg FS. Use of topiramate and risk of glaucoma: a case-control study. Am J Ophthalmol. 2012 May. 153(5):827-30. [Medline].

  14. Tse DM, Titchener AG, Sarkies N, Robinson S. Acute angle closure glaucoma following head and orbital trauma. Emerg Med J. 2009 Dec. 26(12):913. [Medline].

  15. Hunter TG, Chong GT, Asrani S, Allingham RR, Blumberg DM. Simultaneous bilateral angle closure glaucoma in a patient with giant cell arteritis. J Glaucoma. 2010 Feb. 19(2):149-50. [Medline].

  16. Singer MS, Salim S. Bilateral acute angle-closure glaucoma as a complication of facedown spine surgery. Spine J. 2010 Sep. 10(9):e7-9. [Medline].

  17. Day AC, Nolan W, Malik A, Viswanathan AC, Foster PJ. Pilocarpine induced acute angle closure. BMJ Case Rep. 2012 May 8. 2012:[Medline].

  18. Choong YF, Irfan S, Menage MJ. Acute angle closure glaucoma: an evaluation of a protocol for acute treatment. Eye (Lond). 1999 Oct. 13 ( Pt 5):613-6. [Medline].

  19. Masselos K, Bank A, Francis IC, Stapleton F. Corneal indentation in the early management of acute angle closure. Ophthalmology. 2009 Jan. 116(1):25-9. [Medline].

  20. Mansouri K, Ravinet E. Argon-laser iridoplasty in the management of uveitis-induced acute angle-closure glaucoma. Eur J Ophthalmol. 2009 Mar-Apr. 19(2):304-6. [Medline].

  21. Sun X, Liang YB, Wang NL, Fan SJ, Sun LP, Li SZ. Laser peripheral iridotomy with and without iridoplasty for primary angle-closure glaucoma: 1-year results of a randomized pilot study. Am J Ophthalmol. 2010 Jul. 150(1):68-73. [Medline].

  22. Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The definition and classification of glaucoma in prevalence surveys. Br J Ophthalmol. 2002 Feb. 86(2):238-42. [Medline]. [Full Text].

  23. Ang LP, Aung T, Chua WH, Yip LW, Chew PT. Visual field loss from primary angle-closure glaucoma: a comparative study of symptomatic and asymptomatic disease. Ophthalmology. 2004 Sep. 111(9):1636-40. [Medline].

  24. Aung T, Friedman DS, Chew PT, et al. Long-term outcomes in asians after acute primary angle closure. Ophthalmology. 2004 Aug. 111(8):1464-9. [Medline].

  25. Aung T, Oen FT, Wong HT, et al. Randomised controlled trial comparing the effect of brimonidine and timolol on visual field loss after acute primary angle closure. Br J Ophthalmol. 2004 Jan. 88(1):88-94. [Medline]. [Full Text].

  26. Blake DR, Nathan DM. Acute angle closure glaucoma following rapid correction of hyperglycemia. Diabetes Care. 2003 Nov. 26(11):3197-8. [Medline].

  27. Bonomi L, Marchini G, Marraffa M, et al. Epidemiology of angle-closure glaucoma: prevalence, clinical types, and association with peripheral anterior chamber depth in the Egna-Neumarket Glaucoma Study. Ophthalmology. 2000 May. 107(5):998-1003. [Medline].

  28. Fourman S. Diagnosing acute angle-closure glaucoma: a flowchart. Surv Ophthalmol. 1989 May-Jun. 33(6):491-4. [Medline].

  29. Fricke TR, Mantzioros N, Vingrys AJ. Management of patients with narrow angles and acute angle-closure glaucoma. Clin Exp Optom. 1998 Nov-Dec. 81(6):255-266. [Medline].

  30. Gohdo T, Tsumura T, Iijima H, Kashiwagi K, Tsukahara S. Ultrasound biomicroscopic study of ciliary body thickness in eyes with narrow angles. Am J Ophthalmol. 2000 Mar. 129(3):342-6. [Medline].

  31. Kramer P, Ritch R. The treatment of acute angle-closure glaucoma revisited. Ann Ophthalmol. 1984 Dec. 16(12):1101-3. [Medline].

  32. Lam D, Tham C, Lai J, et al. Current approaches to management of acute primary angle closure. Curr Opinion Ophthalmol. 2001. 18:146-151.

  33. Lim LS, Aung T, Husain R, Wu YJ, Gazzard G, Seah SK. Acute primary angle closure: configuration of the drainage angle in the first year after laser peripheral iridotomy. Ophthalmology. 2004 Aug. 111(8):1470-4. [Medline].

  34. Lowe RF. Aetiology of the anatomical basis for primary angle-closure glaucoma. Biometrical comparisons between normal eyes and eyes with primary angle-closure glaucoma. Br J Ophthalmol. 1970 Mar. 54(3):161-9. [Medline]. [Full Text].

  35. MacCumber M. Management of Ocular Injuries and Emergencies. 1998. 237-240:

  36. Markowitz SN, Morin JD. Angle-closure glaucoma: relation between lens thickness, anterior chamber depth and age. Can J Ophthalmol. 1984 Dec. 19(7):300-2. [Medline].

  37. Ritch R. Assessing the treatment of angle closure. Ophthalmology. 2003 Oct. 110(10):1867-8. [Medline].

  38. Salmon JF. The management of acute angle-closure glaucoma. Eye (Lond). 1999 Oct. 13 ( Pt 5):609-10. [Medline].

  39. Saw SM, Gazzard G, Friedman DS. Interventions for angle-closure glaucoma: an evidence-based update. Ophthalmology. 2003 Oct. 110(10):1869-78; quiz 1878-9, 1930. [Medline].

  40. Senthil S, Garudadri C, Rao HB, Maheshwari R. Bilateral simultaneous acute angle closure caused by sulphonamide derivatives: a case series. Indian J Ophthalmol. 2010 May-Jun. 58(3):248-52. [Medline]. [Full Text].

  41. Tarongoy P, Ho CL, Walton DS. Angle-closure glaucoma: the role of the lens in the pathogenesis, prevention, and treatment. Surv Ophthalmol. 2009 Mar-Apr. 54(2):211-25. [Medline].

  42. Yusuf IH, Shah M, Shaikh A, James CB. Transscleral cyclophotocoagulation in refractory acute and chronic angle closure glaucoma. BMJ Case Rep. 2015 Sep 30. 2015:[Medline].

  43. Achiron A, Aviv U, Mendel L, Burgansky-Eliash Z. Acute angle closure glaucoma precipitated by olanzapine. Int J Geriatr Psychiatry. 2015 Oct. 30 (10):1101-2. [Medline].

  44. Singh P, Rijal AP. Effectivity of Nd Yag PI in treatment of acute primary angle closure glaucoma. Nepal Med Coll J. 2014 Sep. 16 (1):45-9. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.