Suspected Acute Angle-Closure Crisis
Acute onset eye pain, headache, nausea/vomiting, blurred vision, halos. Mid-dilated non-reactive pupil, corneal edema, elevated IOP
All Pathways
OphthalmologyEmergency
Acute Angle-Closure Crisis (AACC) Management
Acute Angle-Closure Crisis (AACC) Management: Suspected Acute Angle-Closure Crisis → Confirm Diagnosis → Initial Medical Therapy → ⚠️ Pilocarpine Timing.
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action 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
03Action 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)
04Warning ⚠️ Pilocarpine Timing
Pilocarpine ineffective when IOP >40-50 mmHg due to iris sphincter ischemia. Start after IOP begins to decrease
05Decision IOP Response to Medical Therapy?
Reassess in 30-60 minutes. Target IOP reduction sufficient to clear cornea for laser
06Decision Cornea Clear Enough for LPI?
Can iris be adequately visualized for laser peripheral iridotomy?
07Action 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
08Action 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
09Action 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
10Outcome AACC Resolved
IOP controlled, LPI patent, glaucoma monitoring initiated
11Outcome Surgical Referral
Refractory cases: consider lens extraction, filtering surgery, or glaucoma specialist referral
12Action 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
- Path rejoins step 08Shared downstream outcome
13Action 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
- Path rejoins step 06Shared downstream outcome
Guideline Source
AAO Preferred Practice Pattern: Primary Angle-Closure Disease 2020
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address secondary angle closure (neovascular, lens-induced, etc.)
- Pediatric angle closure requires specialist evaluation
- Plateau iris syndrome may require additional procedures beyond LPI
- Does not replace comprehensive ophthalmologic examination
Contraindicated Populations
secondary_angle_closure
Applicable Regions
USEUGlobal
EU: EGS guidelines similar approach
US: AAO PPP 2020 is current standard
Version 1Next review: 2028-01-01
Next steps
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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 2020.
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 2020 (DOI: 10.1016/j.ophtha.2020.10.021).
What are the limitations of the Acute Angle-Closure Crisis (AACC) Management?
Known limitations include: Does not address secondary angle closure (neovascular, lens-induced, etc.); Pediatric angle closure requires specialist evaluation; Plateau iris syndrome may require additional procedures beyond LPI; Does not replace comprehensive ophthalmologic examination. Individual patient factors may require deviation from these recommendations.
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