Immediate medical therapy bundle
› Topical aqueous suppressants
› Timolol 0.5% 1 drop affected eye
› Repeat every 15 minutes for 2 to 3 doses
› Avoid in asthma or COPD with bronchospasm history
› Avoid in second or third degree AV block
› Brimonidine 0.1% to 0.2% 1 drop affected eye
› Repeat every 15 minutes for 2 to 3 doses
› Avoid in infants due to apnea risk
› Caution with hypotension and sedation
› Dorzolamide 2% 1 drop affected eye
› Repeat every 15 minutes for 2 to 3 doses
› Sulfonamide-related reaction caution
› Additive effect with systemic acetazolamide
› Systemic carbonic anhydrase inhibition
› Acetazolamide 500 mg IV once
› Alternative 500 mg PO once if tolerating oral intake
› Follow with 250 mg PO every 6 hours
› Avoid in severe renal impairment
› Acetazolamide contraindication alternatives
› Methazolamide PO when available
› Early hyperosmotic agent with ophthalmology guidance
Miotic therapy timing and selection
› Pilocarpine strategy
› Pilocarpine 1% to 2% 1 drop affected eye
› Use after IOP reduced below 40 mmHg
› Repeat every 15 minutes for 2 doses
› Corneal edema may limit penetration
› Pilocarpine pitfalls
› Ineffective at very high IOP due to iris sphincter ischemia
› Avoid early use when IOP very high
› Avoid if mechanism not pupillary block until ophthalmology confirms
Hyperosmotic therapy for refractory elevation
› Mannitol IV
› Mannitol 0.5 g/kg IV over 20 to 60 minutes
› Alternative up to 1 to 2 g/kg per protocol and tolerance
› Strict fluid status monitoring
› Serum osmolality monitoring when repeated doses used
› Mannitol contraindications and precautions
› Heart failure and pulmonary edema risk
› Severe renal impairment risk
› Hypotension and electrolyte shifts monitoring
› Oral hyperosmotics when appropriate
› Isosorbide 45% solution 220 mL PO once
› Avoid in severe dehydration
› Monitor nausea and vomiting
› Consider glucose effect in diabetes
› Glycerol 1 mL/kg PO diluted with equal volume water
› Contraindicated in diabetes
› Significant nausea risk
› Use only with ophthalmology guidance
Supportive and adjunct care
› Symptom control
› Ondansetron 4 mg IV or PO
› Repeat per nausea control protocol
› Enables oral acetazolamide if needed
› Analgesia
› Acetaminophen PO or IV per weight
› Opioid analgesia if severe pain with monitoring
› Medication avoidance
› Avoid anticholinergic antiemetics when possible
› Mydriasis risk worsening closure
› Use non-anticholinergic alternatives
› Avoid topical mydriatics
› Worsens pupillary block
› Confounds ophthalmology exam
Definitive therapy and follow-through
› Laser peripheral iridotomy
› Affected eye after corneal clearing
› Definitive relief for pupillary block mechanism
› Prevents recurrence
› Fellow eye prophylaxis
› High risk of future acute attack
› Timing per ophthalmology
› Surgical options when laser not feasible
› Surgical iridectomy
› For failed laser or corneal edema preventing laser
› Often combined with lens-based interventions
› Lens extraction pathway
› Phacomorphic angle closure
› Cataract contributing to crowding
Evidence framing for emergency practice
› Guideline strength interpretation
› Strong consensus for immediate IOP lowering prior to definitive iridotomy
› Analogous to Class I recommendation in time-critical care pathways
› Based on ophthalmology society guidance and standard emergency practice
› Evidence grading note
› ACEP-specific A B C levels not routinely published for AACG
› Use local emergency eye guidelines and ophthalmology society guidance for protocoling
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