Acute Angle-Closure Glaucoma — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Acute angle-closure glaucoma?
   Acute eye pain + red eye + blurred vision/halos + markedly raised IOP? (An ophthalmic emergency. Presentation: acute eye pain, headache, nausea/vomiting, red eye, corneal edema, a mid-dilated fixed pupil, halos; markedly raised measured IOP (often 50–80 mmHg). A delay of a few hours can cause permanent vision loss. Goal: rapidly lower IOP, then laser peripheral iridotomy (LPI).)
   • Meets acute angle-closure glaucoma → Urgent IOP lowering + urgent ophthalmology
   • Does not fit → Does not fit
2. [End] Does not fit
   Differentiate other causes of red eye/acute vision loss (iridocyclitis, keratitis, retinal artery occlusion, scleritis, etc.), manage accordingly and consult ophthalmology.
3. [End] Urgent IOP lowering + urgent ophthalmology
   Urgent medical IOP lowering (start together): 1) topical beta-blocker (timolol 0.5%) + alpha-2 agonist (apraclonidine/brimonidine) ± topical carbonic anhydrase inhibitor. 2) Systemic acetazolamide 500 mg IV (orally if not vomiting) → 250 mg q6h (avoid in sulfa allergy/sickle cell). 3) Pilocarpine once IOP falls below ~40–50 (ineffective at high pressure as the iris sphincter is ischemic; do not exceed 4%). 4) For refractory cases, mannitol 1–2 g/kg IV (caution in renal/heart failure). 5) Supine position, antiemetics, analgesia, topical steroids. Measure IOP every 30–60 min. Urgent ophthalmology for laser peripheral iridotomy (LPI), surgery if needed; prophylactic treatment of the fellow narrow angle.

Source guidelines & references

• Acute angle-closure glaucoma (AAO clinical guidance; emergency management)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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