Glaucoma Acute

8/12/2019 Glaucoma Acute

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Glaucoma, Angle Closure, Acute

Background

Angle-closure glaucoma (ACG) is a condition in which the iris is apposed to the

trabecular meshwork at the angle of the anterior chamber of the eye. When the

iris is pushed or pulled anteriorly to block the trabecular meshwork, the outflow of

aueous from the eye is blocked, which causes a rise in intraocular pressure

(!"#). !f closure of the angle occurs suddenly, symptoms are se$ere and

dramatic. !mmediate treatment is essential to pre$ent damage to the optic ner$e

and loss of $ision. !f closure occurs intermittently or gradually, ACG may be

confused with chronic open-angle glaucoma.%&,',, *

Pathophysiology

Angle closure may occur $ia ' mechanisms. +he iris may be pushed forward into

contact with the trabecular meshwork, as in pupillary block or plateau iris, or it

may be pulled anteriorly, as occurs with other inflammatory conditions. !n either

case, the position of the iris causes the normally open chamber angle to close.

Aueous humor that should drain out of the anterior chamber is trapped inside

the eye. #ain, blurred $ision, and nausea may occur if the ensuing rise in

pressure is sudden. Glaucomatous damage to the optic ner$e also may occurdue to the increased !"#, either in a sudden attack or in intermittent episodes

o$er a long period of time.

!ncreased iris thickness, as measured by anterior segment optical coherence

tomography ("C+), is another risk factor for angle-closure glaucoma in the Asian

population.% *

Frequency

United States

ewer than &/ of 01 glaucoma cases are due to ACG. 2yperopes are at

increased risk for acute ACG because their anterior chamber angles are

relati$ely shallow.


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International

ACG is more common than open-angle glaucoma in Asia.

Mortality/Morbidity

Accurate early diagnosis and treatment help pre$ent $isual damage.

Race

3aces with an anatomically narrower angle, such as Asians and 4skimos, ha$e a

higher incidence of ACG than whites. !ncidence among American !ndians is

lower than among whites.

Sex

Among white patients, the incidence of ACG is times higher in women than in

men. !n black patients, men and women are affected eually.

Age

!n older people, incidence of primary ACG increases as the lens enlarges, and

the depth and $olume of the anterior chamber decrease.

Clinical

History

!n acute primary ACG, the anterior chamber angle is blocked suddenly and

!"# rises rapidly, and the patient may present with dramatic symptoms.

o "nset of se$ere ocular pain, nausea and $omiting, headache, and

blurred $ision is sudden.

o #atients may complain of seeing haloes around lights. 2aloes and

blurry $ision are the result of corneal edema.

o +he attack may ha$e been precipitated by pupillary dilation, possibly

during an ophthalmic e5amination. #atients with acute ACG are

e5tremely uncomfortable and distressed.


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1ome patients may e5perience intermittent episodes of partial angle

closure and relati$ely ele$ated !"# without e$er e5periencing a frank

attack of ACG.

#atients may be totally asymptomatic, or they may report incidents of mildpain with slightly blurred $ision or seeing haloes around lights. +hese

symptoms resol$e spontaneously as the angle reopens.

Physical

45amination of a patient who presents with suspected ACG should include

gonioscopy, tonometry, biomicroscopy, and ophthalmoscopy.

o 6iagnosis of ACG is made by gonioscopic $isuali7ation of an

occluded anterior chamber angle.

o +onometry demonstrates an ele$ated !"#, which may be as high as

-8 mm 2g.

o 9iomicroscopy may re$eal a fi5ed or sluggish and middilated pupil, a

shallow anterior chamber, corneal epithelial edema and bullae,

ciliary in:ection, and cells and flare. 6iffuse lacrimation may be

present.

o "phthalmoscopy may re$eal a swollen optic disc in an acute attack

or e5ca$ation if episodes ha$e been chronic. 0nilateral in$ol$ement

and worsening symptoms are common in acute attacks.

!f an attack persists or if se$eral milder incidents of angle closure ha$e

occurred in the past, peripheral anterior synechiae and adhesions may be

$isible between the cornea and iris. #eripheral anterior synechiae may

destroy the trabecular meshwork, while adhesions may cause necrosis

and permanent dilation of the iris.

Glaucoma flecks (also known as flecken glaucoma), or $esicles on the

anterior subcapsular lens, also may be seen if acute angle closure has

occurred in the past.

Gray atrophy of the stroma of the iris pro$ides further e$idence of a prior

attack, if the attack occurred weeks or more prior to e5amination.


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Causes

#upillary block is the most common cause of ACG. ;ormally, aueous

humor is made by the ciliary epithelial cells in the posterior chamber and

flows through the pupil to the anterior segment, where it can drain out of

the eye through the trabecular meshwork and 1chlemm canal. !f contact

occurs between the lens and the iris, aueous accumulates behind the

pupil, increasing posterior chamber pressure and forcing the peripheral iris

to shift forward and block the anterior chamber angle. +he anterior surface

of the iris may be apposed to the posterior surface of the cornea or to the

trabecular meshwork. +his blockage causes accumulation of aueous in

the anterior chamber and an acute rise in !"#.

#lateau iris is a condition in which anterior insertion of the iris to the ciliary

body causes the anterior chamber angle to become occluded on dilation ofthe pupil. +he iris may insert on the anterior edge of the ciliary body, close

to the trabecular meshwork. !t may cause the patient to ha$e genetically

narrow angles despite a normal anterior chamber depth. +he iris also may

appear unusually flat, not bowed as might be e5pected in ACG. "ften, an

element of pupillary block e5ists in cases of plateau iris glaucoma, in which

case peripheral iridectomy will lower !"#. !f the patient continues to

de$elop angle closure on pupillary dilation after iridectomy has been

performed, continue performing miotic therapy to pre$ent recurrence. A

diagnosis of plateau iris can be confirmed with ultrasound biomicroscopy.

2yperopia< #atients with hyperopic eyes are more likely to ha$e shallow

anterior chambers and narrow angles. +hese patients are predisposed to

de$elop ACG.%= *6ilation of the eye may precipitate an attack of acute ACG

because the peripheral iris rela5es when dilated to midposition. When the

iris is rela5ed, it may bow anteriorly and ma5imi7e iris-lens apposition,

possibly causing pupillary block.

1e$eral medications ha$e been implicated in causing acute ACG. 1ulfa-

deri$ati$e medications, including aceta7olamide, sulfametho5a7ole, and

hydrochlorothia7ide, ha$e all been reported to cause acute attacks.

+opiramate, a newer antiepileptic medication, has recently been implicated

in causing acute narrow-angle glaucoma. Also a sulfa-deri$ati$e

medication, topiramate blocks glutamate receptors and is labeled for use in


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treating sei7ures. +he presumed mechanism of angle closure in$ol$es

swelling of the ciliary body with anterior displacement of the lens-iris

diaphragm. 1topping the medication is effecti$e in treating this condition

and reuires a high inde5 of suspicion by the treating physician.

"ther causes< 1e$eral mechanisms can cause the iris-lens diaphragm to

be pushed forward. A space-occupying lesion (eg, tumor, swelling

associated with ciliary body inflammation) may cause the iris to block the

trabecular meshwork. "ther conditions associated with this mechanism

include central retinal $ein occlusion, placement of a scleral buckle, history

of panretinal photocoagulation, and nanophthalmos.

Dierential Diagnoses

Cataract, 1enile 2eadache, >igraine

Con:uncti$itis, Allergic 1ynechia, #eripheral Anterior

Con:uncti$itis, 9acterial

Con:uncti$itis, ?iral

Glaucoma, Angle Closure, Chronic

"ther Proble#s to Be Considered

Acute abdomen

Cluster headache

Gastritis

$orkup

%#aging Studies

0ltrasound biomicroscopy (09>) - +o $isuali7e the angles and

surrounding structures%@,8 *

Anterior segment optical coherence tomography ("C+) - +o $iew the

angles and anterior ocular structures%@ *


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"ther &ests

Gonioscopy

&reat#ent

Medical Care

6efiniti$e treatment of ACG is laser iridotomy, or, if the iris cannot be accessed

by laser, surgical iridectomy. >edical treatment is intended to prepare the patient

for laser iridotomy. +he cornea should be cleared with osmotic agents, the pupil

should be constricted, and !"# should be lowered to pre$ent acute damage to

the optic ner$e.% *

Surgical Care

Baser iridotomy< +reatment of choice for pupillary-block ACG is laser

iridotomy. !ridotomy with an argon or ;d


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returned to normal, and the cornea must be cleared before a definiti$e procedure

can be undertaken. !n acute ACG, se$eral drugs from different classes are used

simultaneously to accelerate and ma5imi7e their pressure-lowering effects.

Alpha'adrenergic agonists

+opical adrenergic agonists, or sympathomimetics, decrease aueous production

and reduce resistance to aueous outflow. Ad$erse effects include dry mouth

and allergenicity.

Brimonidine (Alphagan)

1electi$e alpha'-receptor that reduces aueous humor formation and possibly

increases u$eoscleral outflow.

Dosing

Adult

& gtt "0 bid

Pediatric

D' years< ;ot recommendedE se$ere mental, cardio$ascular, and pulmonary

depression ha$e been reported in pediatric patients

F' years< ;ot established

Interactions

Coadministration with topical beta-blockers may further decrease !"#E tricyclicantidepressants may decrease effects of brimonidineE C;1 depressants such as

barbiturates, opiates, and sedati$es may potentiate effects of brimonidine

Contraindications

6ocumented hypersensiti$ityE patients recei$ing >A"!s


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Precautions

Pregnancy

9 - etal risk not confirmed in studies in humans but has been shown in some

studies in animals

Precautions

Caution in cardio$ascular disease, depression, cerebral or coronary insufficiency,

orthostatic hypotension, 3aynaud syndrome

Apraclonidine (Iopidine) 0.5% !%

#otent alpha-adrenergic agent selecti$e for alpha'-receptors with minimal cross-

reacti$ity to alpha&-receptors. 3educes !"# whether or not accompanied by

glaucoma. 1electi$e alpha-adrenergic agonist without significant local anesthetic

acti$ity. 2as minimal cardio$ascular effect.

Dosing

Adult

& gtt tid in affected eye(s)

Pediatric

;ot established

Interactions

>onitor pulse and 9# freuently when gi$ing cardio$ascular drugsE not for use

concurrently with >A"!s


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Dosing

Adult

& gtt bid in affected eye(s)

Pediatric

;ot established

Interactions

>ay cause bradycardia and asystole when used in combination with systemic

beta-blockers (may cause additi$e effects)

Contraindications

6ocumented hypersensiti$ityE bronchial asthmaE se$ere chronic obstructi$e

pulmonary diseaseE sinus bradycardiaE second- and third-degree A? blockE o$ert

cardiac failureE cardiogenic shock

Precautions

Pregnancy

C - etal risk re$ealed in studies in animals but not established or not studied in

humansE may use if benefits outweigh risk to fetus

Precautions

9eta-blockade may potentiate muscle weakness that is consistent with certain

myasthenic symptoms (eg, diplopia, ptosis, generali7ed weakness)E product may

ha$e sulfites, which may cause allergic-type reactions in certain susceptible

persons


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Beta'olol ophthalmic (Betoptic)

1electi$ely blocks beta&-adrenergic receptors with little or no effect on beta'-

receptors. 3educes !"# by reducing production of aueous humor.

Dosing

Adult

&-' gtt in affected eye(s) bidE consider concomitant therapy if !"# is not at

satisfactory le$el

Pediatric

;ot established

Interactions

>ay ha$e additi$e systemic effects if patient is already on systemic beta-blockers

Contraindications

6ocumented hypersensiti$ityE bronchial asthmaE se$ere chronic obstructi$e

pulmonary diseaseE sinus bradycardiaE second- and third-degree A? blockE o$ertcardiac failureE cardiogenic shock

Precautions

Pregnancy



Precautions

9eta-blockade may potentiate muscle weakness consistent with myasthenic

symptomsE product may ha$e sulfites, which may cause hypersensiti$ity

reactions in susceptible persons


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imolol maleate (imoptic imoptic *) 0.&5% 0.5%

>ay reduce ele$ated and normal !"#, with or without glaucoma, by reducing

production of aueous humor.

Dosing

Adult

& gtt of .'/ or ./ in affected eye(s) bidE if !"# is maintained at satisfactory

le$els, change dosage to & gtt in affected eye(s) d

!f clinical response not adeuate, change dosage to & gtt of ./ solution in

affected eye(s) bidE if !"# is still not at satisfactory le$el, consider concomitant

therapy

Pediatric

Administer as in adults

Interactions

>ay cause bradycardia and asystole when used in combination with systemic

beta-blockers (may cause additi$e effects)

Contraindications

6ocumented hypersensiti$ityE bronchial asthmaE sinus bradycardiaE second- and

third-degree A? blockE se$ere chronic obstructi$e pulmonary diseaseE o$ert

cardiac failureE cardiogenic shock

Precautions

Pregnancy




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Precautions

#roduct may ha$e sulfites, which may cause allergic-type reactions in

susceptible patients

Miotic agents (parasy#patho#i#etics)

Contract ciliary muscle, tightening the trabecular meshwork and allowing

increased outflow of the aueous. >iosis results from action of these drugs on

pupillary sphincter. Ad$erse effects include brow ache, induced myopia, and

decreased $ision in low light.

Pilocarpine ophthalmic (Pilocar Pilagan)

A naturally occurring alkaloid, pilocarpine mimics muscarinic effects of

acetylcholine at postganglionic parasympathetic ner$es. 6irectly stimulates

cholinergic receptors in the eye, decreasing resistance to aueous humor

outflow.

!nstillation freuency and concentration are determined by patients response.

!ndi$iduals with hea$ily pigmented irides may reuire higher strengths. !f otherglaucoma medication also is being used, at bedtime, use gtt at least min before

gel. >ay use alone, or in combination with other miotics, beta-adrenergic

blocking agents, epinephrine, carbonic anhydrase inhibitors, or hyperosmotic

agents to decrease !"#.

Dosing

Adult

& or ' gtt tidHid

Pediatric

;ot established


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Interactions

>ay be ineffecti$e when used concomitantly with nonsteroidal anti-inflammatory

agents

Contraindications

6ocumented hypersensiti$ityE acute inflammatory disease of anterior chamber

Precautions

Pregnancy



Precautions

Warn patients that pilocarpine causes pupillary constriction and may cause

decreased $ision in presence of cataractE also may cause aching pain in eye or

artificial myopia because of increased accommodationE caution in acute cardiac

failure, peptic ulcer, hyperthyroidism, G! spasm, bronchial asthma, #arkinson

disease, recent >!, urinary tract obstruction, and hypertension or hypotension

Prostaglandin analogs

!ncrease u$eoscleral outflow of the aueous. "ne mechanism of action may be

through induction of metalloproteinases in ciliary body, which breaks down

e5tracellular matri5, thereby reducing resistance to outflow through ciliary body.

"atanoprost (alatan) 0.005%

6ecreases !"# by increasing outflow of aueous humor.


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Precautions

Pregnancy



Precautions

>onitor patients for ad$erse reactions to sulfonamidesE may e5perience

paresthesias of e5tremities, tinnitus, taste alterations, or gastrointestinal distress

,etha+olamide (-lauca$s epta+ane)

3educes aueous humor formation by inhibiting en7yme carbonic anhydrase,

which results in decreased !"#.

Dosing

Adult

-& mg #" bidHtid

Pediatric

;ot established

Interactions

Caution in patients on high-dose aspirin or steroid therapyE may increase to5icity

of salicylate, digo5inE coadministration with other diuretics may inducehypokalemiaE decreases effects of lithium and alter e5cretion of other drugs by

alkalini7ing urine


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Contraindications

6ocumented hypersensiti$ityE renal impairment

Precautions

Pregnancy



Precautions

Caution in respiratory acidosis and diabetes mellitusE impairs mental alertness

andHor physical coordinationE hematuria, glycosuria, polyuria, hepaticinsufficiency, bone marrow suppression, thrombocytopeniaHpurpura,

agranulocytosis, urticaria, pruritus, and rash may occur

Dor+olamide (rusopt)

0sed concomitantly with other topical ophthalmic drug products to lower !"#. !fmore than one ophthalmic drug is being used, administer the drugs at least &

min apart. 3e$ersibly inhibits carbonic anhydrase, reducing hydrogen ion

secretion at renal tubule and increases renal e5cretion of sodium, potassium

bicarbonate, and water to decrease production of aueous humor.

Dosing

Adult

& gtt in affected eye(s) tid

Pediatric

;ot established


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Interactions

Coadministration with high-dose salicylate therapy may increase to5icityE may

ha$e additi$e systemic effects if patient is already on oral CA inhibitors

Contraindications

6ocumented hypersensiti$ity

Precautions

Pregnancy



Precautions

Bocal ocular ad$erse effects, primarily con:uncti$itis and lid reactions, may occur

with long-term administration of dor7olamide (discontinue therapy and e$aluate

patient before restarting therapy)

Brin+olamide (A+opt) !%

Cataly7es re$ersible reaction in$ol$ing hydration of carbon dio5ide and

dehydration of carbonic acid. >ay use concomitantly with other topical

ophthalmic drug products to lower !"#. !f more than one topical ophthalmic drug

is being used, administer drugs at least & min apart.

Dosing

Adult

& gtt in affected eye(s) tid


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Pediatric

;ot established

Interactions

>ay ha$e additi$e systemic effects if patient is already on oral CA inhibitors

Contraindications


Precautions

Pregnancy



Precautions



patient before restarting therapy)

Dor+olamide /Cl timolol maleate (Cosopt)

CA inhibitor that may decrease aueous humor secretion, causing a decrease in

!"#. #resumably slows bicarbonate ion formation with subseuent reduction in

sodium and fluid transport.+imolol is a nonselecti$e beta-adrenergic receptor blocker that decreases !"# by

decreasing aueous humor secretion and may slightly increase outflow facility.

9oth agents administered together bid may result in additional !"# reduction

compared with either component administered alone, but reduction is not as

much as when dor7olamide tid and timolol bid are administered concomitantly.


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Dosing

Adult

& gtt into affected eye(s) bidE if more than one topical ophthalmic drug is used,

administer at least & min apart

Pediatric

;ot established

Interactions

Coadministration with high-dose salicylate therapy may increase to5icityE may

ha$e additi$e systemic effects if patient is already on oral CA inhibitors

Contraindications


Precautions

Pregnancy



Precautions



patient before restarting therapy)E product may ha$e sulfites, which may cause

allergic-type reactions in susceptible patients

Follo*'up

Further %npatient Care

9ecause some patients may e5perience transient increases in !"# after

peripheral iridotomy, check e$ery patients !"# & hour after laser


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treatment. !f medical treatment has not been successful by that time,

repeat gonioscopic e5amination to rule out the presence of peripheral

anterior synechiae. !f peripheral anterior synechiae are found, the patient

may need gonioplasty or incisional surgery.

Further "utpatient Care

"nce a peripheral iridotomy has been performed, the patient should

continue using the medications that were chosen to treat the acute

glaucoma for & day after lea$ing the hospital or clinic. Arrange a &-day

posttreatment $isit. At this $isit, check the !"# again, and e5amine the eye.

After & day, the patient may discontinue the antiglaucoma medications that

were used in the acute attack, but the patient should be maintained on

corticosteroids for & week. 45amine the patients other eye gonioscopically and biomicroscopically to

assess for narrow or occluded angles, as well as for e$idence of prior

attacks of ACG. !f e$idence of prior attacks or predisposition for future

angle closure is seen, prophylactic peripheral iridotomy may be

considered.

%npatient + "utpatient Medications

1ee urther "utpatient Care.

Co#plications

Boss of $ision can occur without prompt treatment.

Prognosis

+he prognosis is fa$orable with early detection and treatment.

Patient ,ducation

!nform the patient to promptly seek professional treatment if pain andHor

decreased $ision occur.

Glaucoma Acute

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