Treatment of primary closed angle glaucoma

Latent closed angle glaucoma is treated only if provocative tests are positive or if one eye has previously experienced a subacute or acute attack. Subacute closed angle glaucoma is managed as the acute presentation.

Treatment of acute closed angle glaucoma:

• urgent referral to an ophthalmology department
• if unable to refer immediately
  • reduction of intra-ocular pressure by reducing aqueous secretion - acetazolamide, usually IV since the patient is often vomiting, and because a rapid response is required (1)
  • pupillary constriction - topical pilocarpine or thymoxamine, an alpha receptor antagonist
• management by ophthalmologists include:
  • medical – miotics (pilocarpine 2-4%), systemic agents (acetazolamide), topical antihypertensives
  • laser iridoplasty (2)
  • surgical or laser iridectomy - once the attack has been controlled - rarely surgery may be undertaken as an emergency procedure if medical management fails

The anatomical configuration is invariably bilateral so prophylactic treatment of the other eye should be considered.

Surgery is usually indicated for chronic closed angle glaucoma.

Reference:

• (1) Khaw PT, Shah P, Elkington AR. Glaucoma--1: diagnosis. BMJ. 2004;328(7431):97-9.
• (2) The College of Optometrists 2009. Glaucoma (primary angle closure) (PACG)