Risk Factors:
- Age >60, family history, ↑IOP
- Diabetes, hypertension, myopia, trauma, African/Asian ancestry
Acute Angle-Closure Management:
- Position: Lay flat (improves optic nerve perfusion)
- Symptom Control: Morphine (pain), ondansetron (nausea)
- IOP Reduction:
  - Beta-Blocker: Timolol 0.5% (↓aqueous humour; avoid in asthma, heart block)
  - Alpha-Agonist: Apraclonidine 1% (↓production, ↑outflow)
  - Cholinergic: Pilocarpine 2% (↑outflow via miosis)
  - Carbonic Anhydrase Inhibitor: Acetazolamide IV/oral 500 mg (↓production)
- Referral: Urgent for laser iridotomy or surgery

Glaucoma

Risk Factors

Age >60: Prevalence increases significantly with advancing age.
Family History: Genetic predisposition, especially in primary open-angle glaucoma (POAG).
Elevated IOP (intraocular pressure): Central risk factor across glaucoma subtypes.
Diabetes, Hypertension: Possibly linked to vascular factors and microvascular damage.
Myopia: High myopia can predispose to angle changes and optic nerve vulnerability.
Trauma: Direct injury can damage drainage structures.
Ethnicity: African and Asian ancestries have higher rates of certain glaucoma forms.

Acute Angle-Closure Glaucoma Management

Patient Position
- Lay flat or slightly elevated: Helps improve optic nerve perfusion by facilitating venous return.
- Provide analgesia (morphine if severe pain) and antiemetics (e.g. ondansetron) for symptom control.
IOP Reduction Measures
- Beta-Blocker (topical):
  - Timolol 0.5% eye drops reduce aqueous humour production.
  - Avoid in asthma, COPD, heart block due to systemic β2 and β1 blockade.
- Alpha-Agonist (topical):
  - Apraclonidine 1% or brimonidine: Decrease aqueous humour production and enhance outflow.
- Cholinergic (topical):
  - Pilocarpine 2% constricts the pupil (miosis), pulling the iris away from the trabecular meshwork and increasing aqueous outflow.
  - More effective once IOP is partially lowered.
- Carbonic Anhydrase Inhibitor:
  - Acetazolamide 500 mg IV or oral reduces aqueous production.
  - Monitor for metabolic acidosis, electrolyte disturbances, sulfonamide allergy.
- Osmotic Agents (e.g. IV mannitol) can be used if extremely high IOP and unresponsive to first-line measures.

Definitive Treatment
- Urgent Referral to ophthalmology for laser peripheral iridotomy or surgical intervention to create an alternative pathway for aqueous humour.
- Ongoing prophylaxis for the fellow eye, as it is at high risk of similar angle-closure episodes.

Notes

Acute Angle-Closure Glaucoma: Presents with severe eye pain, blurred vision, halos around lights, red eye, mid-dilated pupil, headache, nausea, vomiting.
Open-Angle Glaucoma: More common overall, often asymptomatic until late; managed with topical IOP-lowering drops (prostaglandin analogues, β-blockers, alpha-agonists, etc.)
Long-Term Monitoring: Once stabilized, patients require regular optic nerve assessments, visual field testing, and IOP checks.

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