Treatment of primary closed angle glaucoma/acute angle closure and angle closure glaucoma

Latent closed angle glaucoma is treated only if provocative tests are positive or if one eye has previously experienced a subacute or acute attack. Subacute closed angle glaucoma is managed as the acute presentation.

Treatment of acute closed angle glaucoma:

• urgent referral to an ophthalmology department
• if unable to refer immediately
  • reduction of intra-ocular pressure by reducing aqueous secretion - acetazolamide, usually IV since the patient is often vomiting, and because a rapid response is required (1)
  • pupillary constriction - topical pilocarpine
    
• management by ophthalmologists include:
  • medical – initial management is with intravenous acetazolamide and topical pilocarpine, beta-blockers, and steroids
  • surgical options includes iridotomy, phacoemulsification, or iridoplasty
    • laser peripheral iridotomy involves creating a small hole in the iris to alleviate pupillary blockage
    • opens up the drainage angle in the anterior chamber, relieving the condition

The anatomical configuration is invariably bilateral so prophylactic treatment of the other eye should be considered.

Reference:

• (1) Khaw PT, Shah P, Elkington AR. Glaucoma--1: diagnosis. BMJ. 2004;328(7431):97-9.
• (2) The College of Optometrists 2009. Glaucoma (primary angle closure) (PACG)
• (3) Dietze J, Blair K, Zeppieri M, Havens SJ. Glaucoma. 2024 Mar 16. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–.