Acute Angle-Closure Glaucoma

AACG = acute pupil block closing the drainage angle, IOP often >50 mmHg, infarcting the optic nerve within hours. Classic: painful red eye, hazy cornea, mid-dilated fixed pupil, halos, vomiting. Start pressure-lowering treatment before the…

AACG Emergency Pathway

The pathway

1 · Recognise

Painful red eye + hazy cornea + mid-dilated fixed pupil
Halos, headache, N&V — mimics migraine/acute abdomen
Globe rock hard vs other eye

2 · Phone ophthalmology

Same-hour discussion
Document visual acuity both eyes

3 · Reduce aqueous production

IV acetazolamide 500mg
Topical timolol 0.5% ± apraclonidine 1%

4 · Open the angle

Pilocarpine 2% (blue eyes) / 4% (brown) — constricts pupil
Lie patient supine — lens falls posteriorly
NEVER dilating drops

5 · Supportive

Analgesia + IV antiemetic (vomiting spikes IOP)
IV fluids if dehydrated

6 · Definitive

Laser peripheral iridotomy once cornea clears — both eyes
Fellow eye risk 40–80%

Drugs

Drug	Dose	Route	Notes
Acetazolamide	500mg	IV	Carbonic anhydrase inhibitor — reduces aqueous production. Avoid in sulfa allergy/severe renal impairment.
Pilocarpine	2% (4% dark iris) 1 drop	TOP	Miosis pulls iris from the angle. Give once IOP starts falling.
Timolol	0.5% 1 drop	TOP	Caution asthma/bradycardia — systemic absorption.
Ondansetron	4mg	IV	Stop vomiting — Valsalva raises IOP further.

When to escalate

Any suspected AACG — same-hour ophthalmology discussion,Acuity worsening despite treatment,IOP not falling within 1 hour of medical therapy,Bilateral symptoms or only-eye involvement — highest urgency

Reference: NICE CKS Glaucoma / College of Optometrists & RCOphth joint guidance

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