Stepwise approach for treatment of APAC

✍ Systemic

☝ acetazolamide 500mg IV

☝ 250mg PO 4×/day

✍ Ipsilateral eye

☝ β-blocker (timolol 0.5% 2×/day ).

☝ Sympathomimetic (apraclonidine 1% ).

☝ Steroid (prednisolone 1% every 30–60min).

☝ Pilocarpine 2% ( controversy)

• once IOP <50mmhg
• twice in first hour, then 4×/day

✍ Admit patient.

✍ Consider

☝ corneal indentation with a 4-mirror goniolens to relieve pupil block

☝ lying the patient supine may allow the lens to fall back away from the iris

☝ analgesics and antiemetics may be necessary.

✍ Pilocarpine 1% is often given to the contralateral eye while awaiting Nd-YAG PI (although some glaucoma specialists advise against this due to a risk of inducing reverse pupil block).

✅Intermediate Treatment of APAC

✍ Check IOP hourly until adequate control.

✍ If IOP not improving

☝ consider systemic hyperosmotics

☝ glycerol PO 1g/kg of 50% solution in lemon juice

☝ mannitol 20% solution IV 1–1.5g/kg).

✍ If IOP still not improving

☝ consider acute Nd-YAG PI (can use topical
glycerin to temporarily reduce corneal oedema).

✍ If IOP still not improving:

☝ review the diagnosis (could this be aqueous misdirection syndrome with a patent PI?).

☝ Consider

• repeating Nd-YAG PI

• proceeding to surgical PI

• argon laser iridoplasty

• paracentesis

• cyclodiode photocoagulation

• emergency cataract extraction

• trabeculectomy.

✅ Definitive Treatment of APAC

✍ Bilateral Nd-YAG or surgical PI.

🛑 NB

✍ Some eyes may develop chronic high IOP
either from

☝ synechial closure

☝ a POAG-like mechanism

☝ require long-term medical ± surgical treatment.

🛑 Clinical highlights regarding timing of PI in AACG 👸👩‍🏫

✅ Treatment of APAC if the IOP cannot be reasonably controlled medically

✍ the PI must be performed immediately.

✍ prophylactic PI for the fellow eye ( in PACG)

✅Treatment of APAC if the pressure is reasonably controlled medically

✍ prophylactic PI for the fellow eye ( in PACG)

✍ defer PI for a few days in the angery eye for the following reasons

☝ Corneal edema and Descemet’s folds make visualization and performing the iridotomy more difficult.

☝ in very shallow AC , the corneal endothelium is closer to the point of laser energy focus and can be damaged from the laser concussion.

☝During the attack the iris is congested edematous and thick enough to make

• the iridotomy more difficult to perform.

• More power may be required to successfully penetrate the iris with more damage to AC structures

• more uncomfortability for the patient with more painful procedure.