In Reply

Letters to the Editor Acute Closed-Angle Glaucoma—An Ophthalmological Emergency by Dr. Simone Nüßle, Prof. Dr. Thomas Reinhard, and PD Dr. Jan Lübke in issue 45/2021

We thank Dr. Hoza for his contribution to the discussion. We agree that in the cited study by Wolfs et al., the risk factors of age and hyperopia are not addressed. The 3% cited by Dr. Hoza describes the proportion of the studied population over 40 years of age who had a shallow anterior chamber depth of grade 0–1, according to the Van Herick method. However, studies have shown that anatomical risk factors have little predictive power in terms of development of acute angle closure. Only 8 of 129 untreated patients with iridotrabecular contact of >180° developed acute angle closure, with a mean follow-up time of 2.7 years (1).

The proposed prophylactic administration of pilocarpine 2% for at-risk patients to reverse mydriasis is a controversial issue in the literature. In 1977, Mapstone examined the effect of pilocarpine 2% after mydriase with cyclopentolate 0.5%, tropicamide 0.5%, or phenylephrine 10% in high-risk patients. Maximum mydriasis with phenylephrine was found to be a safe position, but after subsequent administration of pilocarpine, a significant proportion of patients developed acute angle closure with mid-dilated pupils. Tropicamide-induced mydriasis was also safe provided there was no increase in pressure for one hour. Based on the results, Mapstone considered the use of pilocarpine to be dangerous after phenylephrine and superfluous after tropicamide; he advised against cyclopentolate in at-risk patients (2). In addition, pilocarpine can increase pupillary block by forward displacement and increased rounding of the lens due to contraction of the ciliary muscles (3).

Nevertheless, we of course agree with Dr. Hoza that diagnostic mydriasis in high-risk patients is associated with a certain risk of angle closure, and that this should not be overlooked in everyday clinical practice.

DOI: 10.3238/arztebl.m2022.0096

On behalf of the authors:

PD Dr. med. Jan Lübke

Klinik für Augenheilkunde, Freiburg, Germany

Conflict of interest statement:

The authors declare that no conflict of interest exists.

References

1. Wilensky JT, Kaufman PL, Frohlichstein D, et al.: Follow-up of angle-closure glaucoma suspects. Am J Ophthalmol 1993; 115: 338–46

2. Mapstone R: Dilating dangerous pupils. Br J Ophthalmol 1977; 61: 517–24

3. Yang MC, Lin KY: Drug-induced acute angle-closure glaucoma: a review. J Curr Glaucoma Pract 2019; 13: 104–9

4. Nüßle S, Reinhard T, Lübke J: Acute closed-angle glaucoma—an ophthalmological emergency. Dtsch Arztebl Int 2021; 118: 771–80