Acute Angle Closure Glaucoma

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Notes: 1. Regimen outlined below is once acute angle closure glaucoma secondary to pupillary block has been established.

2. Definitive treatment is surgical (i.e., laser iridectomy, surgical iridectomy, etc.)

3. Medical treatment is needed to facilitate surgical management.

4. Unless contraindicated, we use topical agents (beta blockers, alpha agonists, and carbonic anhydrase inhibitors), systemic carbonic anhydrase inhibitors (do not use sustained release Diamox Sequels), hyperosmolar agents, and topical steroids a. Topical Agents one drop of a beta blocker: timolol maleate or levobunolol 0.5% one drop of an alpha agonist: apraclonidine 1.0% or brimonidine 0.2% one drop of dorzolamide 2% or brinzolamide 1%

one drop of prednisolone acetate 1% Q15-30 minutes for four doses then hourly b. Systemic Agents one dose of acetazolamide 250-500mg orally

5. Recheck the IOP and visual acuity in one hour. If the IOP does not lower and the vision does not improve, we repeat the topical medications and give mannitol l-2g/kg IV over 45 minutes (a 500ml bag of mannitol 20% contains lOOg of mannitol).

6. Once the IOP is lowered, laser iridectomy can be attempted. If IOP does not lower or view is too poor for performing a laser iridectomy, then a surgical iridectomy or guarded filtration procedure may be required.

'From Diagnosis and Therapy of the Glaucoma, 6th ed. St. Louis: C.V. Mosby; 605-623.

2 From Acta Ophthalmol Scand 1995:73:261-263.

3From Arch Ophthalmol 2005:123:1177-1186.

4From Ophthalmology 2005:112:2143-2148.

5From JPediatr 2002:140:485-486: JAAPOS 2001:5:281-284: JPediatr 2001:138:441-443.

"From Chin J Physiol 1995:38:229-234: Acta Obstet Gynecol Scand 1996:75:816-819.

7From Br J Ophthalmol 2002:86:1318-1319.

8From Am J Ophthalmol 2005:139:855-859.

'From Surv Ophthalmol 2001:45:449-454.

6. Neuro-Ophthalmology

A. AGENTS USED IN NEURO-OPHTHALMOLOGY

Drug

Trade

Préparation

Usual Dose

Notes

botulinum toxin

Botox

Injection

Varies depending on the entity being treated

Used in treatment of blepharospasm, strabismus, and hemifacial spasm

cocaine

N/A

Soin, 10%

1 drop, repeat in 1 minute

Used in diagnosis of Horner's syndrome1

edrophonium chloride

Tensilon

IV Soin, lOmg/ml

2-3mg IV (0.2-0.3 cc)2

Used in diagnosis of myasthenia gravis;1 if unresponsive and no side effects seen after 1 min., may give 0.4 cc Q30 sec x 2

hydroxy amphetamine

Paredrine

Soin, 1%

1 drop, repeat in 1 minute

Used in diagnosis of Horner's syndrome1 No longer available in US

methylprednisolone

Solu-Medrol

IV Soin

250 mg IV Q6hr Special (See Below)

Treatment of optic neuritis and giant cell arteritis (see below for further discussion) Traumatic optic neuropathy

pilocarpine

N/A

Soin, 0.125%

1 drop

Lower strength used in diagnosis and treatment of Adie's pupil1

'For protocol, refer to Rhee DJ, Pyfer, MF, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 1999.

2 Potential for causing cholinergic crisis, treatment of which includes IV atropine.

'For protocol, refer to Rhee DJ, Pyfer, MF, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 1999.

2 Potential for causing cholinergic crisis, treatment of which includes IV atropine.

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