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  • Dr. Nour Khatib, MDCM CCFP(EM) MBA

NEW Glaucoma Treatment: Is your mnemonic outdated?


A 64 yo female comes to your office stating she has 2 days of right eye pain, redness and blurry vision. She has also had nausea, vomiting and a headache. You examine her eye and you see injected sclera, a hazy cornea and a fixed pupil. Your EMR notes that Glaucoma runs in her family and she has never seen an ophthalmologist. How do you proceed?

What is Acute Angle Closure Glaucoma (AACG)?

AACG is an ophthalmological emergency with impaired outflow of aqueous humor from the posterior chamber of the eye causing increased intraocular pressure.

Sudden eye pain, blurred vision, headache, N/V, photophobia

--> Increased eye pressure --> Iris is pushed forward --> blindness!

History:

  • Sudden eye pain 


  • blurred vision, 


  • headache, 


  • nausea & vomiting, 


  • photophobia, and 


  • colored halos around lights


  • Family history


  • Medication (see below)

Drugs that precipitate pupillary dilation:

  • adrenergic agents, 


  • anticholingeric, 


  • sulfa drugs, 


  • tricyclic antidepressants, 


  • anticonvulsants, and 


  • antiparkinsonian drugs.


Physical exam

  • Conjunctival injection 


  • Dilated fixed pupil

  • Shallow anterior chamber

  • Firm eye (yes, push gently on the eye with the lid closed - affected eye may feel firmer)

  • Intraoccular Pressure over 20, sometimes over 60 (if your electronic tonometer reads ERROR - this may mean the pressure is even higher!)

  • Hazy cornea

  • Pale optic disc 


You may have been taught the TAPP'M mnemonic for treatment of Acute Angle Closure Glaucoma. However, this should be avoided because:

  • Pilocarpine - avoid as it can worsen glaucoma

  • Apralonidine - can be difficult to obtain in Canada


A new mnemonic based on the teachings by Moosbrugger is ABC PAM:


Alpha agnoist (e.g. Brimonidine 0.1%)

Beta blocker (e.g. Timolol 0.5%)

Carbonic anhydrase inhibitor (e.g. Dorzolamide 2%)

Prostaglandin (Lantanoprost 0.005%)

Acetazolamide orally

Mannitol IV


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