Acute Angle-Closure Crisis (AACC) Management

Algorithm Steps

1. ▶

   Start

   Suspected Acute Angle-Closure Crisis

   Acute onset eye pain, headache, nausea/vomiting, blurred vision, halos. Mid-dilated non-reactive pupil, corneal edema, elevated IOP

   1. ●

      Action

      Confirm Diagnosis

      Measure IOP (typically >40 mmHg), gonioscopy if cornea clear enough, assess for neovascularization

      • IOP typically 40-80 mmHg in AACC
      • Slit lamp: corneal edema, shallow AC, mid-dilated pupil
      • Rule out secondary causes (NVG, lens-induced)
      • Check fellow eye for narrow angles
      1. ●

         Action

         Initial Medical Therapy

         Multi-agent IOP reduction to relieve symptoms and clear cornea

         • Topical beta-blocker (timolol 0.5%)
         • Topical alpha-agonist (brimonidine 0.2% or apraclonidine 1%)
         • Topical carbonic anhydrase inhibitor (dorzolamide 2%)
         • Acetazolamide 500mg IV or PO
         • Pilocarpine 1-2% q15min x4 (once IOP starts to fall)
         1. ⚠

            Warning

            ⚠️ Pilocarpine Timing

            Pilocarpine ineffective when IOP >40-50 mmHg due to iris sphincter ischemia. Start after IOP begins to decrease

         2. ◆

            Decision

            IOP Response to Medical Therapy?

            Reassess in 30-60 minutes. Target IOP reduction sufficient to clear cornea for laser

            1. ◆

               Decision

               Cornea Clear Enough for LPI?

               Can iris be adequately visualized for laser peripheral iridotomy?

               1. ●

                  Action

                  Laser Peripheral Iridotomy (LPI)

                  Definitive treatment - create alternate aqueous pathway

                  • Nd:YAG or argon laser
                  • Superior location (10-2 o'clock) preferred
                  • Confirm patency (transillumination, aqueous flow)
                  • Post-procedure: steroid drops, IOP check
                  1. ●

                     Action

                     Prophylactic LPI to Fellow Eye

                     REQUIRED: Fellow eye at very high risk of AACC

                     • Perform LPI to fellow eye before discharge
                     • 50% risk of AACC in fellow eye within 5 years if untreated
                     • Can be done same session or within days
                     1. ●

                        Action

                        Post-AACC Follow-up

                        Monitor for complications and chronic angle closure

                        • Check IOP 1 hour post-LPI, then 1 day, 1 week
                        • Gonioscopy to assess angle opening
                        • May develop chronic angle-closure glaucoma requiring ongoing treatment
                        • Cataract surgery may be needed for lens-related component
                        1. ✓

                           Outcome

                           AACC Resolved

                           IOP controlled, LPI patent, glaucoma monitoring initiated

                        2. ✓

                           Outcome

                           Surgical Referral

                           Refractory cases: consider lens extraction, filtering surgery, or glaucoma specialist referral

               2. ●

                  Action

                  Alternative Procedures

                  If LPI not possible due to corneal edema

                  • Laser peripheral iridoplasty (LPIP) - contract iris away from angle
                  • Anterior chamber paracentesis (AC tap) - immediate IOP reduction
                  • Continue medical therapy and reattempt LPI when cornea clears
            2. ●

               Action

               Add Osmotic Therapy

               For refractory elevated IOP

               • Mannitol 1-2 g/kg IV over 45 min (if no contraindications)
               • OR Glycerol 1-1.5 g/kg PO (if not diabetic/nauseated)
               • Contraindications: CHF, renal failure