Managing Acute Angle-Closure Glaucoma: Treatment and Care Strategies

Acute angle-closure glaucoma management and treatment options include: 1. Medications: Immediate treatment often involves medications to lower intraocular pressure. These may include carbonic anhydrase inhibitors (e.g., acetazolamide), topical beta-blockers (e.g., timolol), alpha agonists (e.g., apraclonidine),

Hello Doctor: My medical history is as follows: 1.
The first episode of acute angle-closure glaucoma occurred with an intraocular pressure (IOP) of 56 in the left eye.
After medication and eye drops, my IOP returned to normal, and I stopped the medication.
It was a unilateral episode (visual field and optic nerve were normal).
2.
About two years later, acute angle-closure glaucoma recurred with an IOP of 55 in the left eye (unilateral episode).
After medication and eye drops, whenever I stopped the medication, my IOP measured at 26.
After continuous use of the drops, my IOP decreased to 16, but upon stopping the medication, it rose again to 23.
After resuming the drops, it decreased to 16 (visual field and optic nerve were normal).
At that time, a doctor at a small clinic was unclear about why my IOP was rising and mentioned that my optic nerve and visual field were fine.
Later, I went to a large hospital for further examination, and the doctor informed me that my IOP was slightly elevated but not yet at the level of glaucoma (visual field and optic nerve were normal).
After reviewing my medical history, the doctor advised me to continue using the pressure-lowering drops.
About six months later, the doctor suggested I try stopping the medication, but I informed him about my previous episodes of acute angle-closure glaucoma (which may not have been recorded in my prior consultations).
The doctor decided that I should continue using the drops.
I have been using the drops for four years, and my IOP has remained stable (visual field and optic nerve were normal) without progressing to glaucoma.
However, during my recent visit two days ago, my IOP unexpectedly rose to 26.
The doctor prescribed an additional bottle of pressure-lowering drops for me.
I am currently feeling very anxious.
The latest advanced examination showed all normal results, and the doctor measured my IOP more than five times using in-office equipment.
I would like to ask the doctor about my current situation: my IOP is elevated (unilateral), but my visual field and optic nerve are normal.
1.
I found that after having acute angle-closure glaucoma, I should consider peripheral iridectomy as soon as my IOP stabilizes.
Why, despite informing the doctor of my medical history, was the treatment approach to continue using drops without recommending surgery? Is the continuous use of drops intended to prevent future episodes? Is it still best for me to continue using the drops, or would surgery be a better preventive option? How would you manage patients like me? Are there better preventive and treatment options? I am using Timolol 0.5% long-acting and Brimonidine 0.03%.
2.
In my left eye, I have noticed that objects appear more yellow compared to my right eye, and the brightness is dimmer.
The colors in my left eye seem lighter, and it appears slightly hazy.
When looking at yellow streetlights, there is a more pronounced halo effect.
Could this be cataracts? After reviewing my advanced examination report, the doctor did not suggest changing my medication.
I have been using Brimonidine 0.03% for four years; could this medication be the cause? Due to the treatment, I have been using many medications, which has led to some floaters and haziness.
My left eye vision fluctuates between 1.0 and sometimes 0.7 or lower, but it seems to improve with good sleep and artificial tears.
3.
I found that if one eye has had acute angle-closure glaucoma, the other eye also has a chance of developing it.
Initially, I was prescribed pressure-lowering drops for both eyes, but after informing the doctor that both episodes occurred in my left eye, he advised me to stop the drops in my right eye and only use them in my left eye.
Should I also be using drops in my right eye, or are there preventive measures I can take? Do you have any recommendations? 4.
Can I wear sunglasses? I have read that they may potentially trigger acute angle-closure glaucoma.
I am very anxious and nervous every time I go to see an ophthalmologist, fearing there might be issues with my eyes.
I want to do everything I can to protect my eyes.
Although the doctors have told me that everything is fine during my examinations, I still feel scared.
I have not consulted another doctor, but I happened to find this opportunity to ask questions.
I appreciate your clarification.

Xiao Wei, 30~39 year old female. Ask Date: 2022/04/24

Dr. He Jianxian reply Ophthalmology

In the case of an acute glaucoma attack, it is generally necessary to urgently lower intraocular pressure.
If the pressure can be successfully reduced, subsequent treatment involves laser iridotomy, and emergency surgery becomes an unavoidable option.
After the acute phase of treatment, some individuals may return to normal conditions without the need for additional treatment, only requiring regular follow-ups.
However, some individuals may still have elevated intraocular pressure and will need glaucoma medications for pressure reduction.
Based on your description, you likely do not have acute angle-closure glaucoma; rather, it seems to be a sudden increase in intraocular pressure due to a temporary anterior chamber angle and inflammation.
Typically, short-term treatment with corticosteroids and pressure-lowering medications is sufficient.
Recurrences may happen, and further treatment can be administered as needed.
This is provided for your reference.
Dr.
He Jianxian, Ophthalmology Department, Nantou Hospital.

Reply Date: 2022/04/24

More Info

Managing acute angle-closure glaucoma (AACG) is a critical aspect of ophthalmology, particularly for patients with a history of recurrent episodes. Your case presents a complex scenario, and it’s understandable to feel anxious given the fluctuations in your intraocular pressure (IOP) and the potential for vision loss associated with AACG.

Understanding Acute Angle-Closure Glaucoma
AACG occurs when the drainage angle of the eye becomes blocked, leading to a rapid increase in IOP. This condition can cause severe pain, nausea, vomiting, and visual disturbances. The fact that you have experienced multiple episodes of AACG in your left eye indicates a predisposition to this condition, which can be influenced by anatomical factors such as a shallow anterior chamber or a narrow angle.

Treatment Strategies
1. Medications: The initial management of AACG typically involves medications to lower IOP. These may include topical beta-blockers, alpha agonists, carbonic anhydrase inhibitors, and prostaglandin analogs. It appears that you have been on a regimen of IOP-lowering drops for an extended period, which has helped stabilize your pressure. The recent increase in IOP to 26 mmHg, despite ongoing treatment, is concerning and warrants further investigation.

2. Surgical Options: For patients with a history of AACG, surgical intervention is often recommended to prevent future episodes. Peripheral iridotomy (PI) is a common procedure that creates a small hole in the peripheral iris, allowing aqueous humor to bypass the blocked angle. This procedure can be particularly beneficial for patients like you, who have experienced multiple episodes. The decision to proceed with surgery often depends on the severity of the angle closure, the frequency of attacks, and the overall health of the optic nerve.

3. Monitoring and Follow-Up: Continuous monitoring of IOP and visual field testing is essential. Your ophthalmologist may recommend regular follow-ups to ensure that your IOP remains stable and that there are no signs of optic nerve damage.

Addressing Your Concerns
1. Why Not Surgery?: Your ophthalmologist may have opted to continue with medical management due to the current stability of your visual fields and optic nerve health. However, given your history, it is reasonable to discuss the possibility of surgical intervention, especially if your IOP remains elevated despite medication.

2. Preventive Measures: Since you have a history of AACG in one eye, it is prudent to monitor the other eye closely. Your doctor may recommend starting IOP-lowering drops in the right eye as a preventive measure, even if it has not experienced an episode. Regular eye exams are crucial for early detection of any changes.

3. Visual Symptoms: The symptoms you describe, such as differences in brightness and color perception between your eyes, could be related to several factors, including the effects of prolonged medication use or the onset of cataracts. It’s essential to discuss these symptoms with your ophthalmologist, who can evaluate your eyes thoroughly.

4. Sunglasses and Eye Protection: Wearing sunglasses is generally safe and can protect your eyes from UV damage. However, if you have concerns about triggering an episode of AACG, it’s best to consult with your eye doctor about the types of sunglasses that are appropriate for you.

Conclusion
Your anxiety regarding your eye health is understandable, especially with a history of AACG. It’s essential to maintain open communication with your ophthalmologist about your concerns and treatment options. If you feel uncertain about your current treatment plan, seeking a second opinion from another eye care professional may provide additional reassurance and clarity. Remember, proactive management and regular monitoring are key to preventing future episodes and preserving your vision.

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