✅ Immediate 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.
