Acute Angle-Closure Glaucoma Diagnosis and Treatment

Emergency Evaluation and Diagnosis

The American Academy of Ophthalmology recommends immediate ophthalmologic evaluation for patients with red flag symptoms, including eye pain, severe headache, eye redness, nausea, vomiting, sudden vision loss, and mid-dilated pupil, as these may indicate acute angle-closure glaucoma 3
The presence of bilateral halos, transient blurred vision, and self-resolving episodes is pathognomonic for intermittent angle-closure, which can progress to acute angle-closure crisis if left untreated 2
A thorough history and physical examination, including visual acuity assessment, intraocular pressure measurement, pupil examination, slit-lamp examination, and gonioscopy, are essential for diagnosing acute angle-closure glaucoma 1, 3

The American Academy of Ophthalmology recommends immediate medical therapy to lower intraocular pressure, including topical beta-blockers, topical alpha2-agonists, topical carbonic anhydrase inhibitors, and oral or intravenous hyperosmotic agents, for patients with acute angle-closure crisis 3
Definitive treatment for acute angle-closure crisis includes laser peripheral iridotomy (LPI) in the affected eye, with prophylactic LPI in the fellow eye to prevent future acute attacks 4, 2
For intermittent angle-closure, LPI is the definitive treatment once gonioscopy confirms iridotrabecular contact, and both eyes require treatment given the bilateral nature of primary angle-closure disease 2

The American Academy of Ophthalmology recommends monitoring for persistent intraocular pressure elevation after laser peripheral iridotomy, as some patients may have plateau iris configuration that persists after iridotomy 3
Avoid delaying fellow eye prophylaxis after treating one eye for angle-closure, as acute attacks can occur within days 2
Do not dismiss transient symptoms as benign, even if the patient is asymptomatic at presentation, as these represent warning episodes before potentially blinding acute attacks 2