Management of Pain on Eye Dilation

Immediate Clinical Assessment

The American Academy of Ophthalmology recommends performing gonioscopy in a dark room using a four-mirror lens with a bright, short beam that does not pass through the pupil to avoid inducing pupillary constriction 1
Patients with anatomically narrow angles are at high risk for acute angle-closure crisis, and the American Academy of Ophthalmology suggests assessing for these angles 3, 4
The American Academy of Ophthalmology identifies risk factors for angle closure, including Asian descent, hyperopia, older age, female gender, and short axial length 2

The American Academy of Ophthalmology recommends caution when dilating patients with suspected occludable angles, as it can precipitate acute angle closure 1, 5
The American Academy of Ophthalmology suggests warning patients about signs and symptoms of acute angle closure until iridotomy has been performed 1
The American Academy of Ophthalmology recommends having immediate treatment available if acute angle closure is precipitated during the clinic visit 1

The American Academy of Ophthalmology recommends laser peripheral iridotomy (LPI) as the definitive treatment to relieve pupillary block and prevent acute attacks 6, 2
The American Academy of Ophthalmology suggests performing LPI as soon as possible after diagnosis 6, 3
The American Academy of Ophthalmology recommends prophylactic LPI in the fellow eye, as approximately 50% of fellow eyes develop acute angle closure within 5 years 3, 4

The American Academy of Ophthalmology recommends immediately administering topical medications, including beta-adrenergic antagonists, alpha2-adrenergic agonists, and topical carbonic anhydrase inhibitors 6, 7
The American Academy of Ophthalmology suggests adding systemic agents for rapid IOP reduction, including oral or intravenous carbonic anhydrase inhibitors and oral or intravenous hyperosmotic agents 6, 7
The American Academy of Ophthalmology recommends performing laser iridotomy as soon as corneal clarity permits 6, 7

The American Academy of Ophthalmology suggests considering plateau iris syndrome if pain on dilation persists after LPI has been performed, and treatment options include peripheral laser iridoplasty, chronic miotic therapy, or other surgical procedures 3, 4
The American Academy of Ophthalmology recommends considering neuropathic ocular pain when symptoms significantly outweigh clinical signs, and treatment differs completely from angle-closure disease 2

The American Academy of Ophthalmology states that chronic miotic therapy is NOT an appropriate alternative to iridotomy for either prophylaxis or treatment, as approximately 40% of fellow eyes treated with miotics alone still develop acute angle closure within 5 years 3, 4

The American Academy of Ophthalmology recommends following patients at appropriate intervals with repeat gonioscopy to monitor for increasing peripheral anterior synechiae 3, 4
The American Academy of Ophthalmology suggests monitoring for secondary angle closure from cataract progression and increased lens thickness 3, 4
The American Academy of Ophthalmology recommends considering cataract extraction as a treatment option, as growing evidence shows substantial IOP lowering in some PAC and PACG patients 6