AZARGA ( Brinzolamide+ Timolol ) twice each ten minutes in addition to Pilocarpine 2%

How about Cosopt? would combination drops (Timolol + CAI or brimonidine) be better than individual components? Are there studies that investigate this?

The first consideration in choosing topical medications in AACG is the IOP, if the IOP is 40mmHg or above, then absorption of topical medications will be hampered. After lowering IOP with systemic medication and/or AC paracentesis then we choose which topical medication would work best based the the ACG mechanism that we think is present. If lenticular then Pilocarpine is not ideal cause this would induce more pupillary block and if the iris is still ischemic and prevents proper absorption, then the Pilocarpine will not have mitotic effect but may even cause forward rotation of the ciliary muscle causing more angle closure. Topical CAI are not as potent to break pupillary block and if ALPI/LI is contemplated, the use of CAI may cause slower resolution of corneal edema which compromises the delivery of laser energy. Alpha2 agonist i.e. Brimonidine BID/TID would be my choice as it is fast acting, duration of of action is about 12hrs and IOP reduction achieved is from 20-30% by several mechanism: decrease aqueous production, some effect of episcleral venous pressure and uveoscleral outflow. Some literatures have also shown Brimonidine to cause some degree of miosis which can address ITC as well. Combination timolol and brimonidine BID is also an option.

Agree with Dr Reyes

 My congratulations to Dr.'s Reyes and Robaei for their understanding of AACG. Dr. Reyes summation of the effect of pilocarpine is entirely correct, if the IOP is above 40 mm Hg, the effect is minimal and it may cause forward rotation of the ciliary body and actually worsen the angle closure. All other medical treatment is palliative, as AACG is a SURGICAL disease, as pointed out by Dr. Robaei. Aqueous suppressants have limited absorption with corneal edema, hyperosmotics may be employed depending on the medical condition of the patient.

 So the definitive treatment is PI, whether laser or invasive. A few suggestions:

1. If the cornea is too edematous to allow a laser PI, consider a few drops of topical

   glycerin to help clear the cornea, scraping the epithelium may also help.

2. A paracentesis at the slit lamp to lower IOP acutely may help to clear the cornea for a PI.

3. Consider a peribulbar block for patient comfort/co-operation.

4. If unable to pentrate the iris for a PI, consider iridoplasty, 500 micron spot,

   0.5 sec. duration, power 300-600mw.

5. If the eye AL is less than 22 mm, consider a lens-induced/ciliary block mechanism, measure AC depth and place a drop of cyclopentolate and measure AC depth 45 min. later, check angle with UBM if available.

6,Finally, in a short eye that has a patent PI and the attack persists despite cycloplegia, lens extraction with IOL placement/primary capsulotomy is curative.