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ophtho.acute-angle-closure-glaucoma.core.v1PRODUCTION
ophtho.acute-angle-closure-glaucoma.core.v1

Acute angle-closure glaucoma (AACG)

general_internal_medicineacutesubacuteadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a SIGHT-THREATENING ophthalmic emergency masquerading as a systemic illness — the trap is mislabelling severe eye pain + headache + vomiting as acute abdomen, migraine, or gastroenteritis (Weinreb JAMA 2014 PMID 24825645). IOP reduction is the only proven means of preventing irreversible optic-nerve damage; chronic open-angle management, the migraine pathway, and the SAH pathway are routed OUT, not authored here.

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AACG-emergency scope confirmed; not-this-engine pathways routed by engine_id

Patient inputs (15)

Vagally-mediated nausea/vomiting accompanies severe IOP elevation and is the feature that misdirects to acute abdomen / gastroenteritis / migraine; it also precludes oral CAI dosing (AAO PPP Gedde Ophthalmology 2021)

A mid-dilated (4-6 mm), vertically-oval, fixed/poorly-reactive pupil is near-pathognomonic for AACG and pivots away from uveitis (small/miotic pupil) and conjunctivitis (normal pupil) (AAO PPP Gedde Ophthalmology 2021)

Steamy/hazy oedematous cornea + shallow/flat anterior chamber is the structural signature; a deep chamber and clear cornea argue strongly against AACG (AAO PPP Gedde Ophthalmology 2021)

IOP (often 40-80 mmHg in a crisis) defines diagnosis, urgency, and the IOP→time-to-irreversible-optic-nerve-damage curve; the single most actionable measurement (Weinreb JAMA 2014 PMID 24825645; AAO PPP Gedde Ophthalmology 2021)

Topiramate / sulfonamide / sympathomimetic / anticholinergic / TCA / antihistamine / daratumumab are precipitants; topiramate-class causes idiosyncratic bilateral ciliochoroidal-effusion secondary closure that does NOT respond to iridotomy (Agarwal Indian J Ophthalmol 2019 PMID 31436195; Alzendi Saudi J Ophthalmol 2021 PMID 34085015; Edwards J Glaucoma 2020 PMID 32487951)

Severe acute unilateral eye/brow pain is the dominant AACG symptom; bilateral simultaneous onset shifts the prior toward drug-induced secondary angle closure (AAO PPP Gedde Ophthalmology 2021 PMID 34933744; Agarwal Indian J Ophthalmol 2019 PMID 31436195)

Coloured haloes around lights reflect corneal epithelial oedema from acutely raised IOP — a high-LR AACG pointer that is absent in conjunctivitis and uveitis (Weinreb JAMA 2014 PMID 24825645)

Sulfonamide allergy gates systemic/topical carbonic-anhydrase-inhibitor use (acetazolamide, dorzolamide) — a core bundle drug (AAO PPP Gedde Ophthalmology 2021)

Thunderclap / "worst headache of life" / focal neurology mandates SAH exclusion before anchoring on AACG — recognise then route OUT to neuro.sah.core.v1 (Weinreb JAMA 2014 PMID 24825645)

Gonioscopy (when cornea clears) ± anterior-segment OCT / UBM confirms appositional angle closure and distinguishes pupillary-block from plateau-iris / ciliochoroidal-effusion (lens-vault) mechanisms — drives definitive procedure choice (AAO PPP Gedde Ophthalmology 2021; Emanuel Curr Opin Ophthalmol 2014 PMID 24463418)

Hyperopia / short axial length / prior angle-closure episode / family history elevates the pretest prior and flags the anatomically-crowded fellow eye for prophylactic iridotomy (AAO PPP Gedde Ophthalmology 2021)

Acetazolamide causes hypokalaemia/metabolic acidosis; mannitol shifts volume/osmolality — baseline electrolytes/glucose support safe bundle delivery and monitoring (AAO PPP Gedde Ophthalmology 2021)

Pregnancy gates acetazolamide (avoid first trimester / near term) and mannitol (volume/teratogenic caution) in the IOP-lowering bundle (AAO PPP Gedde Ophthalmology 2021)

Renal function gates acetazolamide and mannitol dosing/contraindication (anuria, severe renal impairment) (AAO PPP Gedde Ophthalmology 2021)

Heart failure / asthma-COPD / heart block gates systemic carryover of topical timolol (β-blockade) and mannitol volume load (Weinreb JAMA 2014 PMID 24825645)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningirreversible_optic_nerve_damage_time_window
    Markedly raised IOP (often 40-80 mmHg) sustained for hours — the IOP×duration window in which retinal-ganglion-cell/optic-nerve loss becomes irreversible (Weinreb JAMA 2014 PMID 24825645; AAO PPP Gedde Ophthalmology 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_iop_needs_surgery
    IOP not broken within ~1 h of the topical + systemic CAI ± mannitol bundle (Weinreb JAMA 2014 PMID 24825645; AAO PPP Gedde Ophthalmology 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsah_or_secondary_cause_mimic
    Thunderclap / "worst headache of life" / focal neurology / meningismus with eye pain and vomiting — subarachnoid haemorrhage or other neuro-emergency mimic (Weinreb JAMA 2014 PMID 24825645)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebilateral_or_fellow_eye_anatomic_risk
    Anatomically narrow/occludable fellow eye after a symptomatic index attack, or bilateral simultaneous closure (AAO PPP Gedde Ophthalmology 2021; He Lancet 2019 PMID 30878226)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredrug_precipitant_active_secondary_closure
    Bilateral simultaneous angle closure on active topiramate / sulfonamide / daratumumab / sympathomimetic — drug-induced ciliochoroidal-effusion secondary mechanism (Agarwal Indian J Ophthalmol 2019 PMID 31436195; Edwards J Glaucoma 2020 PMID 32487951)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevomiting_precludes_oral_carbonic_anhydrase_inhibitor
    Persistent nausea/vomiting preventing oral acetazolamide intake (AAO PPP Gedde Ophthalmology 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesulfonamide_allergy_to_acetazolamide
    Documented sulfonamide allergy with a need for carbonic-anhydrase inhibition (AAO PPP Gedde Ophthalmology 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute angle-closure crisis — stepwise IOP-lowering bundle (bridge) → definitive laser PI
axis: aacg_iop_lowering_bridge_to_laserstep 1 - Step 1 — Immediate non-pharmacologic temporising + mechanism gate
Selected step "Step 1 — Immediate non-pharmacologic temporising + mechanism gate" — Suspected/confirmed acute angle-closure crisis at first contact; before pilocarpine is effective at very high IOP
  • supine_positioning
    first line
    positioning
    triggers: acute_crisis_first_contact
    AAO PPP Gedde Ophthalmology 2021 — supine posture lets the lens-iris diaphragm fall back, deepening the angle while the bundle takes effect
  • corneal_indentation_central_pressure
    add on
    mechanical
    triggers: hazy_cornea_high_iop
    AAO PPP Gedde Ophthalmology 2021 — corneal indentation can mechanically force aqueous into the periphery and transiently break appositional closure
  • stat_ophthalmology_activation
    first line
    escalation
    triggers: raised_iop_with_cardinal_signs
    Weinreb JAMA 2014 (PMID 24825645) — IOP reduction is the only proven means of preventing irreversible optic-nerve damage; definitive laser is ophthalmology-delivered and time-critical
  • STOP_precipitant_drug_if_secondary_closure
    first line
    deprescribing
    triggers: topiramate_or_sulfonamide_or_daratumumab, bilateral_simultaneous_onset
    Agarwal Indian J Ophthalmol 2019 (PMID 31436195); Edwards J Glaucoma 2020 (PMID 32487951) — drug-induced ciliochoroidal-effusion secondary closure responds to drug cessation + cycloplegia + steroid, NOT to pilocarpine or iridotomy

ed playbook — drug actions (6)

  1. 1. timolol ophthalmic
    rxcui 10600
    0.5% 1 drop • ophthalmic • once, repeat per ophthalmology
    trigger: Raised IOP, no severe asthma/heart block (AAO PPP Gedde Ophthalmology 2021)
    Aqueous suppression — first topical agent
  2. 2. brimonidine ophthalmic
    rxcui 134615
    0.2% 1 drop • ophthalmic • once, repeat per ophthalmology
    trigger: Raised IOP (AAO PPP Gedde Ophthalmology 2021)
    α2-agonist aqueous suppression + uveoscleral outflow
  3. 3. dorzolamide ophthalmic
    rxcui 60207
    2% 1 drop • ophthalmic • once, repeat per ophthalmology
    trigger: Raised IOP, sulfonamide-tolerant (AAO PPP Gedde Ophthalmology 2021)
    Topical CAI adjunct
  4. 4. acetazolamide
    rxcui 167
    500 mg • IV (PO if tolerating) • once, then per ophthalmology
    trigger: Inadequate topical response, no sulfonamide allergy, acceptable renal function (AAO PPP Gedde Ophthalmology 2021)
    Potent systemic aqueous suppressant; IV if vomiting
  5. 5. pilocarpine ophthalmic
    rxcui 8328
    1-2% 1 drop • ophthalmic • after IOP partly lowered, per ophthalmology
    trigger: Primary pupillary block, IOP partly lowered (Weinreb JAMA 2014 PMID 24825645)
    Miosis to pull iris from angle — ineffective at very high IOP, give after aqueous suppression; NOT in drug-induced secondary closure
  6. 6. mannitol
    rxcui 6628
    1-2 g/kg of 20% • IV • over 30-60 min, once
    trigger: Refractory IOP, no decompensated HF, adequate renal function (AAO PPP Gedde Ophthalmology 2021)
    Hyperosmotic rescue when topical/systemic measures fail

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Severe acute unilateral eye/brow pain with blurred vision and coloured halos around lights (classic AACG triad — AAO PPP Gedde Ophthalmology 2021 PMID 34933744); Acute red painful eye with frontal headache and nausea/vomiting — the systemic-mimic presentation that masquerades as acute abdomen / migraine / gastroenteritis (Weinreb JAMA 2014 PMID 24825645); Exam finding: red eye + mid-dilated fixed/oval poorly-reactive pupil + steamy/hazy cornea + shallow anterior chamber (cardinal AACG sign cluster — AAO PPP Gedde Ophthalmology 2021).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute angle-closure glaucoma (AACG)** (ophtho.acute-angle-closure-glaucoma.core.v1).
Phenotype framing: Terminal differential of the red painful eye with headache/vomiting, with named pivots: AACG (mid-dilated fixed pupil + steamy cornea + raised IOP + shallow AC + halos pivot) vs acute anterior uveitis (small/miotic pupil + hypopyon/cells + normal-or-low IOP pivot) vs migraine/cluster headache (normal eye exam + normal IOP + photophobia-without-corneal-oedema pivot) vs conjunctivitis (discharge + normal pupil + normal IOP + no pain pivot) vs scleritis (boring pain + scleral violaceous hue + normal IOP pivot) vs subarachnoid haemorrhage (thunderclap + neurology + normal IOP → route to neuro.sah.core.v1 pivot)
Scope: Frame as a SIGHT-THREATENING ophthalmic emergency masquerading as a systemic illness — the trap is mislabelling severe eye pain + headache + vomiting as acute abdomen, migraine, or gastroenteritis (Weinreb JAMA 2014 PMID 24825645). IOP reduction is the only proven means of preventing irreversible optic-nerve damage; chronic open-angle management, the migraine pathway, and the SAH pathway are routed OUT, not authored here.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute angle-closure crisis — stepwise IOP-lowering bundle (bridge) → definitive laser PI** — step "Step 1 — Immediate non-pharmacologic temporising + mechanism gate".
1. supine_positioning (positioning, first line) — AAO PPP Gedde Ophthalmology 2021 — supine posture lets the lens-iris diaphragm fall back, deepening the angle while the bundle takes effect
2. corneal_indentation_central_pressure (mechanical, add on) — AAO PPP Gedde Ophthalmology 2021 — corneal indentation can mechanically force aqueous into the periphery and transiently break appositional closure
3. stat_ophthalmology_activation (escalation, first line) — Weinreb JAMA 2014 (PMID 24825645) — IOP reduction is the only proven means of preventing irreversible optic-nerve damage; definitive laser is ophthalmology-delivered and time-critical
4. STOP_precipitant_drug_if_secondary_closure (deprescribing, first line) — Agarwal Indian J Ophthalmol 2019 (PMID 31436195); Edwards J Glaucoma 2020 (PMID 32487951) — drug-induced ciliochoroidal-effusion secondary closure responds to drug cessation + cycloplegia + steroid, NOT to pilocarpine or iridotomy

Setting playbook (ed) — Recognise the systemic-mimic AACG presentation, measure IOP, start the stepwise medical IOP-lowering bundle within minutes, and obtain STAT same-day ophthalmology for definitive laser PI (AAO PPP Gedde Ophthalmology 2021 PMID 34933744; Weinreb JAMA 2014 PMID 24825645)
5. timolol ophthalmic 0.5% 1 drop ophthalmic once, repeat per ophthalmology — Raised IOP, no severe asthma/heart block (AAO PPP Gedde Ophthalmology 2021) (Aqueous suppression — first topical agent)
6. brimonidine ophthalmic 0.2% 1 drop ophthalmic once, repeat per ophthalmology — Raised IOP (AAO PPP Gedde Ophthalmology 2021) (α2-agonist aqueous suppression + uveoscleral outflow)
7. dorzolamide ophthalmic 2% 1 drop ophthalmic once, repeat per ophthalmology — Raised IOP, sulfonamide-tolerant (AAO PPP Gedde Ophthalmology 2021) (Topical CAI adjunct)
8. acetazolamide 500 mg IV (PO if tolerating) once, then per ophthalmology — Inadequate topical response, no sulfonamide allergy, acceptable renal function (AAO PPP Gedde Ophthalmology 2021) (Potent systemic aqueous suppressant; IV if vomiting)
9. pilocarpine ophthalmic 1-2% 1 drop ophthalmic after IOP partly lowered, per ophthalmology — Primary pupillary block, IOP partly lowered (Weinreb JAMA 2014 PMID 24825645) (Miosis to pull iris from angle — ineffective at very high IOP, give after aqueous suppression; NOT in drug-induced secondary closure)
10. mannitol 1-2 g/kg of 20% IV over 30-60 min, once — Refractory IOP, no decompensated HF, adequate renal function (AAO PPP Gedde Ophthalmology 2021) (Hyperosmotic rescue when topical/systemic measures fail)

Non-pharmacologic actions:
- Lay the patient supine; corneal indentation by ophthalmology to break appositional closure (AAO PPP Gedde Ophthalmology 2021)
- Topical prednisolone 1% for anterior-segment inflammation (AAO PPP Gedde Ophthalmology 2021)
- STAT ophthalmology referral for definitive laser peripheral iridotomy — do not delay (Weinreb JAMA 2014 PMID 24825645)
- STOP the precipitant drug + cycloplegia + steroid (NOT pilocarpine/iridotomy) if drug-induced secondary closure (Agarwal Indian J Ophthalmol 2019 PMID 31436195)

AVOID / contraindication checks:
- Sulfonamide allergy block acetazolamide and dorzolamide (AAO PPP Gedde Ophthalmology 2021 — use β blocker/α2 agonist/mannitol instead)
- Pilocarpine ineffective above iop 40 50 give after aqueous suppression (Weinreb JAMA 2014 PMID 24825645 — ischaemic iris sphincter is unresponsive at very high IOP)
- Pilocarpine and iridotomy contraindicated in drug induced ciliochoroidal effusion secondary closure (Agarwal Indian J Ophthalmol 2019 PMID 31436195 — worsens it; stop drug + cycloplegia + steroid)
- Timolol systemic absorption caution severe asthma copd heart block decompensated hf (Weinreb JAMA 2014 PMID 24825645)
- Mannitol avoid decompensated heart failure anuria severe renal impairment and caution pregnancy (AAO PPP Gedde Ophthalmology 2021)
- Acetazolamide renal and pregnancy dose gating and hypokalaemia acidosis monitoring (AAO PPP Gedde Ophthalmology 2021 — calc.ckd_epi_2021)

Monitoring

Regimen monitoring:
- IOP recheck q30-60min during bundle expect fall within 1h (AAO PPP Gedde Ophthalmology 2021)
- escalate to mannitol then urgent laser surgery if attack not broken in ~1h (Weinreb JAMA 2014 PMID 24825645)
- acetazolamide electrolytes acid base monitoring (AAO PPP Gedde Ophthalmology 2021)
- mannitol volume status and electrolyte osmolality monitoring (AAO PPP Gedde Ophthalmology 2021)
- post LPI IOP and iridotomy patency check plus fellow eye prophylaxis completed (AAO PPP Gedde Ophthalmology 2021 PMID 34933744)

Setting (ed) monitoring:
- IOP recheck q30-60 min — expect a fall within ~1 h on an effective bundle (AAO PPP Gedde Ophthalmology 2021)
- Antiemetic for vomiting + IV route for acetazolamide if oral not tolerated (AAO PPP Gedde Ophthalmology 2021)

Follow-up plan: Definitive LPI of the affected eye and PROPHYLACTIC LPI of the anatomically-narrow fellow eye (untreated fellow-eye attack risk is substantial in symptomatic angle closure — distinct from screen-detected ZAP suspects where prophylaxis benefit is modest, He Lancet 2019 PMID 30878226); EAGLE early-lens-extraction discussion in lens-driven disease (Azuara-Blanco Lancet 2016 PMID 27707497); lifelong glaucoma surveillance for residual optic-nerve damage / chronic angle closure; permanent documentation + deprescribing of the precipitant drug and patient warning card; route chronic IOP care and precipitant medication review out by engine_id
- Close-out criterion: definitive + fellow-eye laser plan documented; precipitant deprescribed/flagged; chronic glaucoma surveillance arranged

Monitoring phase: Recheck IOP at 30-60 min intervals during the bundle; expect a meaningful fall within ~1 h on an effective bundle — failure to break the attack mandates escalation to mannitol then urgent laser/surgery, not silent continuation; monitor for acetazolamide hypokalaemia/acidosis and mannitol volume overload/electrolyte shift; post-LPI IOP check and patency confirmation

Disposition

Current setting: ed — Recognise the systemic-mimic AACG presentation, measure IOP, start the stepwise medical IOP-lowering bundle within minutes, and obtain STAT same-day ophthalmology for definitive laser PI (AAO PPP Gedde Ophthalmology 2021 PMID 34933744; Weinreb JAMA 2014 PMID 24825645)

Disposition criteria:
- STAT same-day ophthalmology in every case for definitive laser PI (AAO PPP Gedde Ophthalmology 2021 PMID 34933744)
- Refractory IOP / prolonged attack / vomiting precluding oral therapy / bilateral secondary closure → admit or transfer for IV mannitol + urgent laser/surgery
- Responsive primary pupillary-block with arranged same-day LPI + reliable follow-up → ophthalmology-directed urgent outpatient laser

Escalation triggers (move to higher acuity):
- IOP not broken within ~1 h of topical + systemic CAI → IV mannitol then urgent laser/surgery (Weinreb JAMA 2014 PMID 24825645)
- Thunderclap/worst-headache/focal-neurology → route to neuro.sah.core.v1 (recognise, not managed here)
- Bilateral simultaneous secondary closure needing systemic therapy → admit + route precipitant review to gim.deprescribing.core.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Markedly raised IOP (often 40-80 mmHg) sustained for hours — the IOP×duration window in which retinal-ganglion-cell/optic-nerve loss becomes irreversible (Weinreb JAMA 2014 PMID 24825645; AAO PPP Gedde Ophthalmology 2021)
- [LIFE_THREATENING] IOP not broken within ~1 h of the topical + systemic CAI ± mannitol bundle (Weinreb JAMA 2014 PMID 24825645; AAO PPP Gedde Ophthalmology 2021)
- [LIFE_THREATENING] Thunderclap / "worst headache of life" / focal neurology / meningismus with eye pain and vomiting — subarachnoid haemorrhage or other neuro-emergency mimic (Weinreb JAMA 2014 PMID 24825645)

Citations

- AAO Primary Angle-Closure Disease Preferred Practice Pattern (Gedde et al, Ophthalmology 2021;128:P30-P70) + EAGLE clear-lens-extraction RCT (Azuara-Blanco et al, Lancet 2016) + ZAP prophylactic-LPI RCT (He et al, Lancet 2019) + Weinreb/Aung/Medeiros JAMA 2014 glaucoma pathophysiology & treatment review + Emanuel/Parrish/Gedde Curr Opin Ophthalmol 2014 evidence-based PAC management [PMID:34933744](https://pubmed.ncbi.nlm.nih.gov/34933744/)
- Cited evidence (PMID 27707497) [PMID:27707497](https://pubmed.ncbi.nlm.nih.gov/27707497/)
- Cited evidence (PMID 30878226) [PMID:30878226](https://pubmed.ncbi.nlm.nih.gov/30878226/)
- Cited evidence (PMID 35568336) [PMID:35568336](https://pubmed.ncbi.nlm.nih.gov/35568336/)
- Cited evidence (PMID 35501120) [PMID:35501120](https://pubmed.ncbi.nlm.nih.gov/35501120/)

Last reconciled with current guidelines: 2026-05-17.
References
  • AAO Primary Angle-Closure Disease Preferred Practice Pattern (Gedde et al, Ophthalmology 2021;128:P30-P70) + EAGLE clear-lens-extraction RCT (Azuara-Blanco et al, Lancet 2016) + ZAP prophylactic-LPI RCT (He et al, Lancet 2019) + Weinreb/Aung/Medeiros JAMA 2014 glaucoma pathophysiology & treatment review + Emanuel/Parrish/Gedde Curr Opin Ophthalmol 2014 evidence-based PAC management — PMID:34933744
  • Cited evidence (PMID 27707497) — PMID:27707497
  • Cited evidence (PMID 30878226) — PMID:30878226
  • Cited evidence (PMID 35568336) — PMID:35568336
  • Cited evidence (PMID 35501120) — PMID:35501120