Suspected acute angle-closure crisis (AACC)
Eye pain, headache, nausea or vomiting, blurred vision with halos. Red eye, cloudy cornea, mid-dilated pupil with poor or no light reaction, very high IOP.
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OphthalmologyEmergency
Acute Angle-Closure Crisis (AACC) Management
Acute Angle-Closure Crisis (AACC) Management: Suspected acute angle-closure crisis (AACC) → Confirm AACC and call ophthalmology now → Topiramate, sulfon...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Confirm AACC and call ophthalmology now
Sight-threatening emergency. Laser and procedures need an ophthalmologist. Start medical therapy while you wait. No ophthalmologist on site: phone the regional ophthalmology service and arrange urgent transfer.
- Measure IOP: often above 40 mmHg (can reach 50-70 mmHg)
- Slit lamp: corneal oedema, shallow anterior chamber, mid-dilated pupil, ciliary injection
- Gonioscopy of both eyes when the cornea allows (ophthalmologist)
- Ask about recent drugs: topiramate, sulfonamides, anticholinergics, adrenergics (e.g. salbutamol), dilating eye drops
03Decision Topiramate, sulfonamide or other secondary angle closure suspected?
Suspect it if: recent topiramate or a sulfonamide (often both eyes, with a new myopic shift), new iris vessels, uveitis, swollen or dislocated lens, intraocular gas or oil, or recent eye surgery. Attack after dilating drops, anticholinergic or adrenergic drugs is pupillary block: answer No and treat as primary AACC.
- If Yes
04Action Topiramate, sulfonamide or other secondary angle closure: urgent ophthalmology
Pilocarpine and laser iridotomy do not treat these mechanisms, and pilocarpine can make effusion or lens-related closure worse.
- Topiramate or sulfonamide: stop the drug now (with the prescriber)
- No pilocarpine. Acetazolamide is also a sulfonamide: ophthalmology to choose IOP drugs
- While you wait: topical timolol or brimonidine and IV mannitol as ophthalmology advises (check contraindications)
- Ophthalmology: cycloplegia and topical steroid as indicated
- Other secondary causes: treat the cause and lower IOP medically or surgically
05Outcome Secondary angle closure: specialist care
Manage under ophthalmology. This pathway covers primary AACC only.
If No06Warning Check contraindications before the drugs
Child or adolescent: adult doses do not apply; ask ophthalmology. Omit a drug that is contraindicated and give the others.
- Asthma or past asthma, severe COPD, bradycardia, 2nd or 3rd degree heart block, overt heart failure: no timolol
- Sulfonamide allergy, low K or Na, GFR below 10 mL/min, marked liver disease, pregnancy: no acetazolamide
- Taking an MAOI, or child under 2 years: no brimonidine
07Action Primary AACC: give all first-line drugs together now
Adult doses. Topiramate, sulfonamide and other secondary angle closure excluded. Attacks after dilating drops or anticholinergic or adrenergic drugs are treated here. Lowers IOP, relieves pain and clears the cornea for laser.
- Timolol 0.5%: 1 drop to the affected eye
- Brimonidine 0.2%: 1 drop to the affected eye
- Acetazolamide 500 mg IV or oral once (adult); further doses as ophthalmology directs. Renal impairment (GFR above 10 mL/min): halve the dose
- Pilocarpine 1% or 2%: 1 drop to the affected eye. It works mainly after IOP falls. No intensive repeated dosing
- Topical steroid as directed by ophthalmology
- Treat pain and vomiting. Avoid drugs with anticholinergic effects
08Decision IOP falling and cornea clearing within 1 hour?
Recheck IOP and the cornea 30-60 minutes after the drugs.
- If Yes
09Decision Cornea clear enough for laser iridotomy?
Ophthalmologist decides if the iris can be seen well enough for laser peripheral iridotomy (LPI).
- If Yes
10Action Cornea clear: laser peripheral iridotomy (LPI), affected eye
Definitive treatment for pupillary block. Do it as soon as it is safe.
- Nd:YAG laser (thermal laser pre-treatment helps in dark irides)
- Confirm patency by seeing aqueous and pigment flow; transillumination alone is not enough
- Check IOP within 30 min to 2 h after the laser
- Topical steroid after the laser
11Decision Patent iridotomy and IOP controlled?
Ophthalmologist confirms after LPI or after the other procedures.
- If Yes
12Action Controlled: prompt LPI to the fellow eye if its angle is narrow
About half of untreated fellow eyes have an attack within 5 years, sometimes within days.
- Examine the fellow eye with gonioscopy
- Narrow angle: prophylactic LPI promptly
- Long-term pilocarpine is not a substitute for LPI
13Action Follow-up after AACC (ophthalmology)
Intervals are set by the ophthalmologist.
- Confirm LPI patency and measure IOP at each visit
- Dark-room gonioscopy with indentation: angle opening and PAS
- Optic nerve imaging and visual fields for glaucoma
- Consider early lens extraction (discretionary; ophthalmologist decides)
14Outcome AACC resolved: long-term glaucoma follow-up
IOP controlled, LPI patent in both eyes where indicated. Review for chronic angle-closure glaucoma.
If No15Outcome Not controlled or LPI not possible: surgical escalation
Ophthalmologist: dark-room gonioscopy for other mechanisms (e.g. plateau iris); incisional iridectomy, or lens extraction with or without goniosynechialysis, or trabeculectomy. Also treat the fellow eye.
If No16Action Cornea not clear: ophthalmologist clears the view or breaks the attack
Then do LPI as soon as the view allows.
- Topical glycerin to clear the cornea
- Corneal indentation (compression) to break pupillary block
- Laser peripheral iridoplasty (works through a cloudy cornea)
- Anterior chamber paracentesis (high risk if the anterior chamber is very shallow)
- Path rejoins step 11Shared downstream outcome
If No17Action IOP still high after 1 hour: add IV mannitol
Not in anuria, severe hypovolaemia, pulmonary oedema or severe heart failure. Check renal, cardiac and fluid status first.
- Mannitol 20%: 1-2 g/kg IV over at least 30 min (adult; maximum 2 g/kg). 70 kg: 350-700 mL
- Ophthalmology: laser iridoplasty or paracentesis if the attack is not broken within 1 hour
- Monitor urine output, fluid balance and electrolytes
- Path rejoins step 09Shared downstream outcome
Guideline Source
AAO Preferred Practice Pattern: Primary Angle-Closure Disease 2025
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Primary AACC only: drug-induced (topiramate, sulfonamides) and other secondary angle closure need specialist care
- Adult doses; children and pregnancy need ophthalmology advice
- Plateau iris can need treatment beyond LPI
- Does not replace a full ophthalmic examination
Contraindicated Populations
secondary_angle_closuredrug_induced_angle_closurechildren
Applicable Regions
USEUAUGlobal
AU: IV acetazolamide is on the ARTG (Glaumox 500 mg vial). Apraclonidine is on the ARTG only as 0.5% (Iopidine); use brimonidine 0.2%. No oral glycerol product for this use was found on the ARTG.
EU: European Glaucoma Society Guidelines 5th edition (2020) give the same approach and the drug doses used here.
US: AAO Primary Angle-Closure Disease PPP 2025 is the current US guideline.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Acute Angle-Closure Crisis (AACC) Management?
The Acute Angle-Closure Crisis (AACC) Management is a emergency clinical algorithm for Ophthalmology. It provides a structured decision tree to guide clinical decision-making, based on AAO Preferred Practice Pattern: Primary Angle-Closure Disease 2025.
What guideline is the Acute Angle-Closure Crisis (AACC) Management based on?
This algorithm is based on AAO Preferred Practice Pattern: Primary Angle-Closure Disease 2025 (DOI: 10.1016/j.ophtha.2025.12.030).
What are the limitations of the Acute Angle-Closure Crisis (AACC) Management?
Known limitations include: Primary AACC only: drug-induced (topiramate, sulfonamides) and other secondary angle closure need specialist care; Adult doses; children and pregnancy need ophthalmology advice; Plateau iris can need treatment beyond LPI; Does not replace a full ophthalmic examination. Individual patient factors may require deviation from these recommendations.
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