High Iop On Initial Presentation

Patients presenting with extremely elevated IOP (e.g., >50 mm Hg) usually have symptoms. Unlike the chronically elevated IOP found with primary open-angle glaucoma or some forms of secondary glaucoma, acutely elevated IOP can cause blurry vision, pain, haloes around lights, nausea, vomiting, red eye, and corneal swelling.21 On the other hand, optic nerve or visual field damage is less frequently found with acutely elevated IOP, because the symptoms bring attention to the disorder early on. With chronic IOP elevation, however, disease progression is indolent and may present with severe optic nerve damage despite a lack of symptoms. Table 11.2 lists the most common causes of acutely elevated IOP.

When patients with extremely elevated IOP are evaluated, it is important to perform a complete ophthalmic examination, including gonioscopy. Zeiss gonioscopy is adequate, but in situations where symptoms are uniocular, Koeppe gonioscopy or even ultrasound biomicroscopy or anterior segment optical coherence tomography may be helpful to evaluate possible angle recession or questionably narrow angles. In addition, a thorough history will also provide useful information to help identify the cause of the elevated IOP. A history of diabetes may suggest neovascular glaucoma. A history of sudden visual loss may suggest central retinal vein occlusion with subsequent neovascular glaucoma. Previous surgery may be a clue to angle closure, inflammatory glaucoma, or a steroid response. Intermittent pain and blurred vision may suggest chronic angle-closure glaucoma, while sudden pain and visual loss may suggest acute angle-closure glaucoma. The medical history is also important to elicit any conditions that may be relative contraindications to glaucoma therapy. For example, a history of chronic obstructive pulmonary disease, heart block, or congestive heart failure may make one wary of using beta blockers. CAIs are a poor option in patients with poorly controlled diabetes mellitus, sickle cell anemia, or sulfa allergy.

Once the etiology of the elevated IOP is known, the goal is to lower the pressure as rapidly as possible. In general, the goal IOP is one that is considered safe for the optic nerve. In a young, otherwise healthy patient, an acceptable IOP might be

Table 11.2 Causes of Acute IOP Elevation

Angle-Closure Glaucomas

Open-Angle Glaucomas

Primary Angle Closure Acute angle closure Chronic angle closure Secondary angle closure Neovascular glaucoma Uveitic glaucoma with synechiae Iris bombe Malignant glaucoma Intraocular tumors

Juvenile open-angle glaucoma Secondary open-angle glaucoma Postoperative changes Pseudoexfoliation syndrome Pigment dispersion syndrome Angle recession Uveitic glaucoma Steroid response Carotid-cavernous fistula

Table 11.3 Medical Treatment of Extremely Elevated 1OPa

Medication

Marked IOP and Symptoms

High IOP With Mild Symptoms

Beta blockers Alpha agonists Carbonic anhydrase inhibitors Osmotics

Q 10min x 2, then Q 12 hours Q 10min x 2, then Q 12 hours CAI Q 10min x 2, then Q 8 hours or acetazolamide 500 mg iv Mannitol 1-2 g/kg iv (20% solution)

Q 10min x 2, then Q 12 hours Q 10 min x 2, then Q 12 hours CAI Q 10min x 2, then Q 8 hours or acetazolamide 500 orally Oral glycerine 1-1.5 g/kg po (50% solution)

aPilocarpine is often used in angle-closure glaucoma.

slightly higher than in an elderly patient with other underlying systemic illnesses, such as diabetes mellitus. The mainstay of therapy for extremely elevated IOP includes aqueous suppressants and osmotics. Miotics are generally used in cases of angle-closure glaucoma or open-angle glaucoma without inflammation. Table 11.3 lists general guidelines for managing acutely elevated IOP.

After receiving medication in the office for severely elevated IOP, patients should have their IOP rechecked after 45 minutes to 1 hour. If the IOP level is acceptable, patients may be sent home with detailed medication cards, with the understanding that they must be seen the next day to ensure that the IOP remains controlled with medications. If compliance issues or a lack of an adequate support system makes return visits seem unlikely, then the decision to admit the patient to the hospital for eye drop administration and closer observation may be appropriate. In addition, if the IOP is not adequately reduced after initial treatment, the patient may also be admitted for overnight observation and repeat IOP checks during the course of the day or night. If IOP cannot be adequately controlled with appropriate medical and/ or laser treatment—in the case of angle-closure glaucoma—then incisional surgery, such as a trabeculectomy, should be considered.

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