Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

initial presentation: acute angle-closure glaucoma

1st line – carbonic anhydrase inhibitors and/or topical beta-blocker and/or topical alpha-2 agonist

Back
ACUTE
|
initial presentation: acute angle-closure glaucoma
1st line – 

carbonic anhydrase inhibitors and/or topical beta-blocker and/or topical alpha-2 agonist

Carbonic anhydrase inhibitors decrease aqueous humour formation and are used commonly as first-line therapy in combination with beta-blockers and alpha-2 agonists. Topical dorzolamide and brinzolamide are preferred over systemic acetazolamide and methazolamide. Topical beta-blockers lower intra-ocular pressure (IOP) through suppression of aqueous humour production. Beta-blockers reduce IOP by around 20% to 25%.[36] Topical alpha-2 adrenergic agonists lower IOP through suppression of aqueous humour production. Alpha-agonists reduce IOP by around 18% to 35%.[36] 

Primary options

dorzolamide ophthalmic: (2%) 1 drop into the affected eye(s) twice or three times daily

or

brinzolamide ophthalmic: (1%) 1 drop into the affected eye(s) twice or three times daily

or

acetazolamide: 125-250 mg orally (immediate-release) up to four times daily, maximum 1000 mg/day; 250-500 mg intravenously every 2-4 hours, maximum 1000 mg/day

or

methazolamide: 50-100 mg orally twice or three times daily

-- AND / OR --

timolol ophthalmic: (0.25% or 0.5%) 1 drop into the affected eye(s) twice daily; (0.5% gel) 1 drop into the affected eye(s) once daily

or

levobunolol ophthalmic: (0.25%) 1-2 drops into the affected eye(s) twice daily; (0.5%) 1-2 drops into the affected eye(s) once daily

or

betaxolol ophthalmic: (0.5%) 1-2 drops into the affected eye(s) twice daily

-- AND / OR --

brimonidine ophthalmic: (0.1 to 0.2%) 1 drop into the affected eye(s) three times daily

Consider – topical ophthalmic cholinergic agonists

Back
ACUTE
|
initial presentation: acute angle-closure glaucoma
Consider – 

topical ophthalmic cholinergic agonists

Additional treatment recommended for SOME patients in selected patient group

When ACG is suspected to be secondary to pupillary block or plateau iris syndrome and once intra-ocular pressure (IOP) is <40 mmHg, these agents may be incorporated.

These agents cause pupil constriction with thinning of the iris and its pulling away from the inner eye wall and trabecular meshwork, thus opening the angle.

Instillation frequency and concentration of pilocarpine is determined by response. Patients with heavily pigmented irides may require higher strengths.

In acute attack 1% to 2% is the preferred solution. Stronger miotics may increase the pupillary block. They can paradoxically result in shallowing of the anterior chamber and narrowing of the angle in eyes with angle closure secondary to lens-induced mechanism or aqueous misdirection. They are therefore contraindicated in these cases.

Patients may be maintained on pilocarpine as long as IOP is controlled and no deterioration in visual fields occurs.

Primary options

pilocarpine ophthalmic: (1-2%) 1 drop into the affected eye(s) up to four times daily

Consider – hyperosmotic agents

Back
ACUTE
|
initial presentation: acute angle-closure glaucoma
Consider – 

hyperosmotic agents

Additional treatment recommended for SOME patients in selected patient group

If there is failure of initial medical treatment or intra-ocular pressure (IOP) is greater than 50 mmHg, hyperosmotic agents are used to control acute episodes of elevated IOP. They are rarely administered for longer than a few hours because their effects are transient.

Indicated in patients when medical treatments are unsuccessful or if pressures are exceedingly high.

Primary options

mannitol: 1.5 to 2 g/kg intravenously over 30 minutes

Plus – laser peripheral iridotomy after acute attack resolved (after corneal oedema resolves)

Back
ACUTE
|
initial presentation: acute angle-closure glaucoma
Plus – 

laser peripheral iridotomy after acute attack resolved (after corneal oedema resolves)

Treatment recommended for ALL patients in selected patient group

Laser peripheral iridotomy (LPI) is usually successful.[17][39][40][41][42]​​

LPI alleviates pupillary block by allowing aqueous humour to bypass the pupil. The pressure differential between anterior and posterior chambers is eliminated, and the iris loses its convex configuration and falls away from the trabecular meshwork (TM), resulting in opening or widening of the angle. LPI is indicated in all eyes with angle closure and usually in fellow eyes as well, because both eyes usually share the same anatomic predisposition for increased pupillary block and so are at high risk for developing acute angle closure.

An untreated fellow eye has a 40% to 80% risk of developing an acute attack. Therefore, it is recommended that the contralateral eye be treated prophylactically with laser peripheral iridotomy if the chamber angle is found to be anatomically narrow.[17][24][47][48][49]

2nd line – anterior chamber paracentesis

Back
ACUTE
|
initial presentation: acute angle-closure glaucoma
2nd line – 

anterior chamber paracentesis

If the IOP cannot be decreased with medical therapy, an anterior chamber paracentesis can offer immediate resolution. This often results in the clearing of corneal oedema, which can make performing a laser peripheral iridotomy easier. A study showed that this may also benefit the outcomes of eventual surgical intervention.[38]

This prospective trial randomised patients to receive either paracentesis at presentation or no paracentesis at presentation, with both groups going on to have surgery (trabeculectomy). Paracentesis reduced IOP significantly in all patients, without serious adverse events. Post trabeculectomy inflammation was seen in fewer eyes and at a lower level in the paracentesis group. In addition, the percentage of functional filtration blebs, success rate of trabeculectomy, and the rate of visual recovery were statistically significantly higher in the paracentesis group.

Plus – laser peripheral iridotomy after acute attack resolved (after corneal oedema resolves)

Back
ACUTE
|
initial presentation: acute angle-closure glaucoma
Plus – 

laser peripheral iridotomy after acute attack resolved (after corneal oedema resolves)

Treatment recommended for ALL patients in selected patient group

Laser peripheral iridotomy (LPI) is usually successful.[17][39][40][41][42]​​

LPI alleviates pupillary block by allowing aqueous humour to bypass the pupil. The pressure differential between anterior and posterior chambers is eliminated, and the iris loses its convex configuration and falls away from the trabecular meshwork (TM), resulting in opening or widening of the angle. LPI is indicated in all eyes with angle closure and usually in fellow eyes as well, because both eyes usually share the same anatomic predisposition for increased pupillary block and so are at high risk for developing acute angle closure.

An untreated fellow eye has a 40% to 80% risk of developing an acute attack. Therefore, it is recommended that the contralateral eye be treated prophylactically with laser peripheral iridotomy if the chamber angle is found to be anatomically narrow.[17][24][47][48][49]

initial presentation: chronic angle-closure glaucoma

1st line – laser peripheral iridotomy

Back
ACUTE
|
initial presentation: chronic angle-closure glaucoma
1st line – 

laser peripheral iridotomy

Laser peripheral iridotomy (LPI) is usually successful.[17][39][40][41][42]​​

LPI alleviates pupillary block by allowing aqueous humour to bypass the pupil. The pressure differential between anterior and posterior chambers is eliminated, and the iris loses its convex configuration and falls away from the trabecular meshwork (TM), resulting in opening or widening of the angle. LPI is indicated in all eyes with angle closure and usually in fellow eyes as well, because both eyes usually share the same anatomic predisposition for increased pupillary block and so are at high risk for developing acute angle closure.

An untreated fellow eye has a 40% to 80% risk of developing an acute attack. Therefore, it is recommended that the contralateral eye be treated prophylactically with laser peripheral iridotomy if the chamber angle is found to be anatomically narrow.[17][24][47][48][49]

ONGOING

residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure

1st line – topical prostaglandin analogues and/or topical beta-blocker and/or topical alpha-2 agonist

Back
ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
1st line – 

topical prostaglandin analogues and/or topical beta-blocker and/or topical alpha-2 agonist

These agents are typically used individually but may be used in combination as well. They may be used in refractory cases. Latanoprost has been associated with lower incidence of conjuctival hyperaemia than other prostaglandin analogues.[62] Topical ophthalmic prostaglandin analogues work by increasing aqueous outflow, reaching peak effectiveness 10 to 14 hours after administration. They are the most potent intraocular pressure (IOP)-lowering agents. Latanoprost and travoprost are preferred over bimatoprost. Topical beta-blockers lower IOP through suppression of aqueous humour production.

Topical alpha-2 adrenergic agonists lower IOP through suppression of aqueous humour production. Topical cholinergic agonists may or may not need to be continued.

Primary options

latanoprost ophthalmic: (0.005%) 1 drop into the affected eye(s) once daily at night

or

travoprost ophthalmic: (0.004%) 1 drop into the affected eye(s) once daily at night

or

bimatoprost ophthalmic: (0.03%) 1 drop into the affected eye(s) once daily at night

-- AND / OR --

timolol ophthalmic: (0.25% or 0.5%) 1 drop into the affected eye(s) twice daily; (0.5% gel) 1 drop into the affected eye(s) once daily

or

levobunolol ophthalmic: (0.25%) 1-2 drops into the affected eye(s) twice daily; (0.5%) 1-2 drops into the affected eye(s) once daily

or

betaxolol ophthalmic: (0.5%) 1-2 drops into the affected eye(s) twice daily

-- AND / OR --

brimonidine ophthalmic: (0.1 to 0.2%) 1 drop into the affected eye(s) three times daily

or

apraclonidine ophthalmic: (0.5%) 1-2 drops into the affected eye(s) three times daily

Consider – carbonic anhydrase inhibitors

Back
ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
Consider – 

carbonic anhydrase inhibitors

Additional treatment recommended for SOME patients in selected patient group

Carbonic anhydrase inhibitors decrease aqueous humour formation. Topical dorzolamide and brinzolamide are preferred over systemic acetazolamide and methazolamide.

Systemic carbonic anhydrase inhibitor therapy is uncommonly utilised because of the many side effects of systemic use and should be reserved for patients with glaucoma refractory to other medical treatment.[36]

Primary options

dorzolamide ophthalmic: (2%) 1 drop into the affected eye(s) twice or three times daily

OR

brinzolamide ophthalmic: (1%) 1 drop into the affected eye(s) twice or three times daily

Secondary options

acetazolamide: 125-250 mg orally (immediate-release) up to four times daily, maximum 1000 mg/day; 250-500 mg intravenously every 2-4 hours, maximum 1000 mg/day

OR

methazolamide: 50-100 mg orally twice or three times daily

Consider – argon laser peripheral iridoplasty (when there is a component of plateau iris)

Back
ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
Consider – 

argon laser peripheral iridoplasty (when there is a component of plateau iris)

Additional treatment recommended for SOME patients in selected patient group

If residual angle closure occurs in the presence of patent LPI, then further laser surgery should be performed. Argon laser peripheral iridoplasty (ALPI) is a procedure during which contraction burns are placed in the peripheral iris with the aim of thinning it and pulling it away from the TM.

Consider – lens extraction surgery ± goniosynechialysis

Back
ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
Consider – 

lens extraction surgery ± goniosynechialysis

Additional treatment recommended for SOME patients in selected patient group

If residual angle closure is attributable to the lens pushing forward the iris, then lens extraction surgery with or without goniosynechialysis is considered.

Consider – topical cholinergic agonists

Back
ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
Consider – 

topical cholinergic agonists

Additional treatment recommended for SOME patients in selected patient group

Cholinergic agents may be used if there is residual angle closure after laser treatment. These agents cause pupil constriction with thinning of the iris and its pulling away from the inner eye wall and TM, thus opening the angle.

Instillation frequency and concentration of pilocarpine is determined by response. Patients with heavily pigmented irides may require higher strengths.

In acute attack 1% to 2% is the preferred solution. Stronger miotics may increase the pupillary block.

Patients may be maintained on pilocarpine as long as intra-ocular pressure is controlled and no deterioration in visual fields occurs.

Primary options

pilocarpine ophthalmic: (1-2%) 1 drop into the affected eye(s) up to four times daily

Consider – trabeculectomy or tube shunt implantation

Back
ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure
Consider – 

trabeculectomy or tube shunt implantation

Additional treatment recommended for SOME patients in selected patient group

Uncommonly intra-ocular pressure (IOP) remains elevated despite medical and surgical measures, and in this case IOP-lowering surgery, such as trabeculectomy or tube shunt implantation, is indicated.[60][61] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

repeat episode of acute angle-closure glaucoma

1st line – reassessment

Back
ONGOING
|
repeat episode of acute angle-closure glaucoma
1st line – 

reassessment

If the mechanism of angle closure has not been eliminated, an acute episode can recur. In this case, in addition to standard treatment of the acute episode, the clinician should look for the specific mechanism of angle closure and treat it accordingly. It is important in such cases to verify that the peripheral iridotomy is patent.

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer