Increased IOP, shallow or partially flat anterior chamber with anterior iris bowing (iris bombé), absence of a patent PI. Posterior iris adhesions to lens, anterior capsule, or intraocular lens usually present.

1. If the cornea is clear and the eye is not significantly inflamed, a PI is performed, usually by YAG laser. Because the PI tends to close, it is often necessary to perform two or more iridotomies. See Appendix 15, YAG LASER PERIPHERAL IRIDOTOMY.
2. If the cornea is hazy, the eye is inflamed, or a PI cannot be performed immediately, then:
   • Mydriatic agent (e.g., cyclopentolate 2% and phenylephrine 2.5%, every 15 minutes for four doses).
   • Topical therapy with β-blocker (e.g., timolol 0.5%), α2 agonist (e.g., brimonidine 0.1% to 0.2%), and CAI (dorzolamide 2%) should be initiated immediately if no contraindication. In urgent cases, three rounds of these medications may be given, with each round being separated by 15 minutes.
   • Systemic CAI (e.g., acetazolamide 250 to 500 mg i.v. or two 250-mg tablets p.o. in one dose if unable to give i.v.) if IOP decrease is urgent or if IOP is refractory to topical therapy.
   • Topical steroid (e.g., prednisolone acetate 1%) every 15 to 30 minutes for four doses.
   • PI, preferably YAG laser, when the eye is less inflamed. If the cornea is not clear, topical glycerin may help clear it temporarily.
   • A surgical PI may be needed.
   • A guarded filtration procedure or tube shunt may be needed if the angle has become closed.