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 – topical or systemic carbonic anhydrase inhibitor and/or topical beta-blocker and/or topical alpha-2 agonist

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

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

Management of an acute episode necessitates lowering potentially harmful high intraocular pressure (IOP) to relieve pain and reduce pain and corneal oedema.[1]

Topical or systemic carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide, acetazolamide, methazolamide), topical beta-blockers (e.g., timolol, betaxolol), and topical alpha-2 agonists (e.g., brimonidine) may be used as first-line therapies alone, but more typically in combination. These drugs lower IOP through suppression of aqueous humour production.[1]​ Topical dorzolamide and brinzolamide are preferred over systemic acetazolamide and methazolamide. Topical beta-blockers reduce IOP by approximately around 20% to 25%.[39]​ Topical alpha-2 agonists reduce IOP by approximately 18% to 35%.[39]

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 cholinergic agonist

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

topical cholinergic agonist

Additional treatment recommended for SOME patients in selected patient group

In patients in whom angle closure is thought to be secondary to pupillary block or plateau iris syndrome, topical cholinergic agents (e.g., pilocarpine) should be started after intraocular pressure (IOP) decreases to <40 mmHg.[39]

Cholinergic agents are contraindicated in angle closure secondary to a lens-induced mechanism or aqueous misdirection; they can, paradoxically, result in shallowing of the anterior chamber and narrowing of the angle in these eyes.[17]​ Corneal indentation may help break pupillary block.[1]

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.

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 – systemic hyperosmotic agent

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

systemic hyperosmotic agent

Additional treatment recommended for SOME patients in selected patient group

Systemic hyperosmotic agents (e.g., mannitol) should be used if the above medical treatments are unsuccessful. They are rarely administered for longer than a few hours because their effects are transient. Hyperosmotic agents are also used initially when pressures are exceedingly high.[1]

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)

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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

Definitive treatment is aimed at achieving a persistently open angle and alleviation of pupillary block. The preferred treatment is laser peripheral iridotomy (LPI).[1][39]​ LPI should be performed in the fellow eye when indicated (i.e., if the chamber angle is found to be anatomically narrow).[1]

One meta-analysis of two randomised controlled trials found that eyes treated with iridotomy (where a laser is used to make an opening in the iris) had wider angles at 1 and 5 years compared with eyes that received no iridotomy.[42]​ Eyes undergoing iridotomy experienced fewer peripheral anterior synechiae at 5 years than eyes that received no iridotomy.[42]​ The effects of iridotomy on eye pressure and vision were, however, limited. Of note, studies included in the meta-analysis enrolled patients at risk of developing primary angle-closure glaucoma (PACG), rather than patients with PACG.

Factors associated with persistent angle closure after LPI include narrower angle, thick iris, an anteriorly positioned ciliary body, and a greater lens vault.[43]​ If the iridotomy becomes occluded, pupillary block may recur, and repeat iridotomy is indicated. Retreatment with laser surgery or a surgical iridectomy may be needed.[1]

2nd line – anterior chamber paracentesis

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

anterior chamber paracentesis

If the intraocular pressure cannot be decreased with medical therapy, an anterior chamber paracentesis can offer immediate resolution.[40][41]​​ This often results in the clearing of corneal oedema, which can make performing a laser peripheral iridotomy easier.[41]

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

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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

Definitive treatment is aimed at achieving a persistently open angle and alleviation of pupillary block. The preferred treatment is laser peripheral iridotomy (LPI).[1][39]​ LPI should be performed in the fellow eye when indicated (i.e., if the chamber angle is found to be anatomically narrow).[1]

One meta-analysis of two randomised controlled trials found that eyes treated with iridotomy (where a laser is used to make an opening in the iris) had wider angles at 1 and 5 years compared with eyes that received no iridotomy.[42]​ Eyes undergoing iridotomy experienced fewer peripheral anterior synechiae at 5 years than eyes that received no iridotomy.[42]​ The effects of iridotomy on eye pressure and vision were, however, limited. Of note, studies included in the meta-analysis enrolled patients at risk of developing primary angle-closure glaucoma (PACG), rather than patients with PACG.

Factors associated with persistent angle closure after LPI include narrower angle, thick iris, an anteriorly positioned ciliary body, and a greater lens vault.[43]​ If the iridotomy becomes occluded, pupillary block may recur, and repeat iridotomy is indicated. Retreatment with laser surgery or a surgical iridectomy may be needed.[1]​

initial presentation: chronic angle-closure glaucoma

1st line – laser peripheral iridotomy

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

laser peripheral iridotomy

Definitive treatment is aimed at achieving a persistently open angle and alleviation of pupillary block. The preferred treatment is laser peripheral iridotomy (LPI).[1][39]​ LPI should be performed in the fellow eye when indicated (i.e., if the chamber angle is found to be anatomically narrow).[1]

One meta-analysis of two randomised controlled trials found that eyes treated with iridotomy (where a laser is used to make an opening in the iris) had wider angles at 1 and 5 years compared with eyes that received no iridotomy.[42]​ Eyes undergoing iridotomy experienced fewer peripheral anterior synechiae at 5 years than eyes that received no iridotomy.[42]​ The effects of iridotomy on eye pressure and vision were, however, limited. Of note, studies included in the meta-analysis enrolled patients at risk of developing primary angle-closure glaucoma (PACG), rather than patients with PACG.

Factors associated with persistent angle closure after LPI include narrower angle, thick iris, an anteriorly positioned ciliary body, and a greater lens vault.[43]​ If the iridotomy becomes occluded, pupillary block may recur, and repeat iridotomy is indicated. Retreatment with laser surgery or a surgical iridectomy may be needed.[1]​ 

ONGOING

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

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

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

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

If IOP remains elevated after surgery, the initial management is with IOP-lowering drugs. First-line options include a topical prostaglandin analogue and/or a topical beta-blocker and/or a topical alpha-2 agonist.[1]

Topical prostaglandin analogues (e.g., latanoprost, travoprost, bimatoprost) are potent IOP-lowering agents, and should be used first-line.[47][48]​ They work by increasing uveoscleral outflow, and reach peak effectiveness 8 to 12 hours after administration.[39]​ Latanoprost and travoprost are preferred over bimatoprost. Latanoprost has been associated with lower incidence of conjunctival hyperaemia than other prostaglandin analogues.[51]​ Topical beta-blockers (e.g., timolol, betaxolol) and alpha-2 agonists (e.g., brimonidine, apraclonidine) are typically used alone, or in combination at the discretion of the physician.

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 – topical or systemic carbonic anhydrase inhibitor

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

topical or systemic carbonic anhydrase inhibitor

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.

Chronic systemic carbonic anhydrase inhibitor therapy is associated with many adverse effects, and should be reserved for patients with glaucoma refractory to other medical treatment.[39]​​

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)

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

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

Additional treatment recommended for SOME patients in selected patient group

Laser iridoplasty can be considered in the presence of a patent LPI with a residual appositional angle.[1]​ In this procedure, an argon laser is used to place contraction burns in the peripheral iris over its entire circumference in order to pull the peripheral iris away from the TM.[44]​

Consider – lens extraction surgery ± goniosynechialysis

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ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure (IOP)
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. Early lens extraction may provide better long-term IOP control, and reduce the need for additional glaucoma agents, compared with laser peripheral iridotomy.[45][46]

Consider – topical cholinergic agonist

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

topical cholinergic agonist

Additional treatment recommended for SOME patients in selected patient group

Topical cholinergic agonists (e.g., pilocarpine) may or may not need to be continued.

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

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ONGOING
|
residual angle closure after laser peripheral iridotomy with elevated intra-ocular pressure (IOP)
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.[49][50] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

repeat episode of acute angle-closure glaucoma

1st line – reassessment

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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.

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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

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