Goal of medical therapy is to 'break the attack' in order to prepare the patient for laser iridotomy.
Timolol 0.5%:
Blocks beta receptors on ciliary epithelium
1 drop in affected eye, repeat in 1 hour if needed.
Acetazolamide:
Blocks productions of HCO3-, which draws Na+ into the eye; water follows by osmosis to form aqueous humour
500mg IV or PO (PO preferred unless patient is nauseated)
Can substitute methazolamide 100mg if patient has renal failure.
Contraindicated in sickle cell patients
Dorzolamide (Trusopt) 2%:
topical carbonic anhydrase inhibitor
1 drop in affected eye
Brimonidine ophthalmic (alphagan) 0.2% OR Apraclonidine ophthalmic 1%:
α agonist will increase trabecular outflow
1 drop in affected eye
Pilocarpine 1%–2%:
Parasympatholytic alkaloid acts on muscarinic receptors found on iris sphincter muscle → causes muscle to contract → miosis → pulls iris away from trabecular network
1 drop in affected eye every 15 minutes x 2-4 doses, then every 4 to 6 hours
Likely does not work until IOP drops below 40-50 mmHg, but still give immediately upon diagnosis
Note: may make fundoscopic evaluation more difficult for ophtho consultant due to miosis
These therapies are usually reserved for failure of other treatments. Hyper osmotic agents such as mannitol are effective but are contraindicated in renal failure and can cause hypotension in the volume depleted patient.
Mannitol: 1-2 g/kg IV given over 45 minutes to minimize cerebral effecfts (most common)
50% glycerin (Osmoglyn) OR 45% isosorbide (Ismotic): 1.5 mL/kg PO (rarely used)
Topical steroids not indicated during<unk>  attack, but may help inflammation after IOP under control.
Prednisolone acetate 1% 1 gtt every 15 to 30 minutes four times, then q1h 
Prednisolone acetate 1% 1 gtt every 15 to 30 minutes four times, then q1h
Acute angle-closure glaucoma
Nontraumatic
Open-angle glaucoma
Acute angle-closure glaucoma^
Orbital cellulitis
Anterior uveitis
Orbital compartment syndrome
Conjunctivitis