Synopsis
Recognise an acute pressure crisis, distinguish pupil block from secondary angle closure, and arrange immediate ophthalmic pressure reduction and definitive treatment.
- Treat the acute symptomatic pressure rise as an emergency even before established glaucomatous optic nerve damage can be demonstrated.
- Record visual acuity, pupils, pressure and anterior chamber depth in both eyes, while arranging urgent ophthalmic review.
- Ask explicitly about topiramate, recent eye surgery and cataract: some secondary mechanisms worsen with pilocarpine.
Key red flags
Abrupt ocular pain and visual deterioration with vomiting or a hazy cornea require emergency eye assessment; do not manage presumed migraine or gastroenteritis without examining the eyes.
Investigation priorities
Establish the severity and document the baseline while arranging treatment.
Management branches
A person presents with abrupt painful visual loss and suspected acute angle closure.
- Contact the receiving eye service immediately, document vision and pupils, and provide appropriate analgesia and antiemetic treatment during assessment.
- Confirm elevated pressure and a closed angle, checking both anterior chambers and the history for secondary lenticular, postoperative or drug-related causes.
Key medicines
Acetazolamide injection for the selected RCOphth acute pathwayThe RCOphth acute-care diagram uses acetazolamide 250 mg intravenously once when intraocular pressure exceeds 40 mmHg; reassess at 30–60 minutes and have ophthalmology determine further dosing and the stop point.
Pilocarpine 2% eye drops for a suitable pupil-block mechanismInstil one drop into the affected eye initially when advised; the RCOphth pathway defers treatment if pressure is above 40 mmHg. Subsequent dosing is approximately every six hours until definitive treatment or specialist review.