Check for sulfa allergy
Acetazolamide 500 mg IV stat and T Diamox 250mg PO QID
G Timolol 0.5% and G Apraclonidine (Iopidine) 1%† stat and then BD (unless contra-indicated)
G Pilocarpine 2% stat then QID to both eyes (avoid intensive Pilocarpine regimen)
G Maxidex stat and QID
Analgesics and anti-emetics as necessary
Patient to lie supine
Stage 2
Recheck IOP after one hour
If IOP not ≤ 40 mm Hg give iv Mannitol 20% at a dose of 1g/kg body weight to be administered over 45 minutes via infusion pump (caution in cardiac and renal patients)‡
50% Glycerol 1g/kg bodyweight in a 50:50 mixture of lemon juice (caution in diabetics) may be given as an alternative. Avoid glycerol if nausea or vomiting present.
Patient lies supine for a further one hour
Stage 3
Recheck IOP after one hour
If IOP not ≤ 40mm Hg
If Mannitol already used in stage 3 discuss with senior colleague
If not already used in stage 3, commence Mannitol 20% at a dose of 1 g/kg body weight intravenously over 45 minutes via infusion pump (caution in cardiac and renal patients)‡
Stage 4
Recheck IOP after one hour
If IOP not reduced discuss with senior colleague
Options include anterior chamber paracentesis, laser iridoplasty/iridotomy
If IOP still not controlled contact glaucoma team
Laser iridotomy
Is the definitive treatment for acute angle-closure
Always discuss with senior colleague prior to laser treatment.
Do not attempt laser if significant inflammation or corneal oedema present or if IOP is too high.
Remember to repeat gonioscopy as initial lowering of IOP in itself is not indicative of success unless it can be demonstrated that the angle has been opened
Footnotes
†Brimonidine may be used as an alternative if Iopidine 1% unavailable
‡Mannitol 10% may be used at the same dose per kg if 20% unavailable