A 64-year-old man presents to the emergency room with a headache and nausea. He reports that he was rocking his grandson to sleep when the symptoms began. He states the pain is constant and is primarily located on his right side. When asked to indicate the area of pain, he says that it surrounds his eye and upper forehead. He had one episode of vomiting. The patient also reports difficulty seeing out of his right eye, which he attributes to excessive tearing. The patient’s past medical history is significant for hypertension. His medications include hydrochlorothiazide. His temperature is 98.6°F (37°C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min. The patient’s right eye is shown in Figure A. Upon physical examination, the right pupil is minimally responsive to light and the globe feels firm. A right-sided carotid bruit is appreciated. Which of the following is the most appropriate prophylaxis for this patient’s condition?
Acetazolamide
Clopidogrel
Amitriptyline
Epinephrine
Acetazolamide
This patient is presenting with sudden-onset unilateral vision loss and an orbitofrontal headache with a dilated pupil and a hard ocular globe suggesting a diagnosis of acute angle-closure glaucoma. Long-term management of angle-closure glaucoma can include acetazolamide.

Examination of the eye in a patient with acute-closure glaucoma will reveal a red eye that is rock-hard and a mid-dilated pupil which is minimally reactive to light. The fundoscopic exam will show an increased optic cup-to-disk ratio (>0.4) and tonometry will show increased intraocular pressure. Gonioscopy is the diagnostic gold standard. Acute treatment and long-term management involve the administration of beta-blockers, alpha-2-agonists, and carbonic anhydrase inhibitors such as acetazolamide to decrease intraocular pressure. The definitive treatment is iridotomy.

Airaksinen et al. review the treatment of closed-angle glaucoma. They discuss how a combination of acetazolamide and beta-blockers can terminate an attack. They recommend using 1 drop of pilocarpine 3 hours after intravenous acetazolamide administration.

Figure/Illustration A is a clinical photograph showing an eye with injected conjunctiva (red circles) and a mid-dilated pupil. These findings are consistent with angle-closure glaucoma.

Incorrect Answers:
Answer B: Amitriptyline can be used as prophylaxis for migraines. Migraines present as unilateral, pulsating headaches that may be associated with nausea or photophobia. Patients with migraines can sometimes experience an aura with visual field changes; however, they would not have exam findings of a rock-hard eye or injection.

Answer C: Clopidogrel may be used as a conservative treatment for carotid atherosclerosis, which can be an embolic source for central retinal artery occlusion (CRAO). CRAO presents as acute, painless, monocular vision loss. A fundoscopic exam will demonstrate ischemia of the retina.

Answer D: Epinephrine is contraindicated in the treatment of angle-closure glaucoma as it increases pupillary dilation. It is used in the management of open-angle glaucoma. This would present with gradually patchy loss of vision and is generally painless.

Answer E: Verapamil is used as prophylaxis for cluster headaches. Cluster headaches present as unilateral, repetitive, brief headaches associated with severe peri-orbital pain, lacrimation, rhinorrhea, and Horner syndrome (miosis, ptosis, and anhidrosis).

Bullet Summary:
Pharmacologic management of acute angle-closure glaucoma involves beta-blockers, alpha-2 agonists, and carbonic anhydrase inhibitors.