The Angle Bench: What Slams It Shut and What Opens It

Intraocular pressure, live

How the first ten minutes went

Nothing chosen yetTick your actions on the left, then score the plan. Two of the options on that list are the ones students reach for by reflex and they both make the pressure worse.

Every drug pulls one of two levers

Class and example	Lever	What you watch
Prostaglandin analogue latanoprost, bimatoprost, travoprost	More uveoscleral outflow	First-line, once daily at bedtime. Permanent brown iris darkening, longer darker lashes, periorbital fat atrophy, hyperaemia. Refrigerate latanoprost until opened. Warn before the patient discovers it.
Beta-blocker timolol, betaxolol	Less production	Bradycardia, hypotension, bronchospasm, fatigue, masked hypoglycaemia. Great caution or avoid in asthma, chronic obstructive pulmonary disease, heart block, decompensated heart failure. Apical pulse first.
Alpha-2 agonist brimonidine, apraclonidine	Less production and more outflow	Dry mouth, allergic conjunctivitis, fatigue, hypotension. Contraindicated in infants and young children and with monoamine oxidase inhibitors — central nervous system depression and apnoea in the very young.
Topical carbonic anhydrase inhibitor dorzolamide, brinzolamide	Less production	Bitter taste, stinging, blurred vision. Sulfonamide-derived — ask about sulfa allergy. Shake brinzolamide, it is a suspension.
Systemic carbonic anhydrase inhibitor acetazolamide	Less production, sharply	For acute angle closure and refractory cases. Monitor potassium, bicarbonate, creatinine; expect paraesthesias, polyuria, metabolic acidosis, malaise. Avoid in sulfa allergy, renal impairment, marked electrolyte derangement.
Rho-kinase inhibitor netarsudil	More trabecular outflow	Conjunctival hyperaemia is very common, plus corneal verticillata and small conjunctival haemorrhages. Reassure, but report pain or vision change.
Cholinergic miotic pilocarpine	Constricts the pupil, pulls iris off the meshwork	Mainly angle closure. Brow ache, dim vision especially at night, accommodative spasm. Fall precautions and no night driving.

Punctal occlusion belongs to every drop. Press the inner canthus for one to two minutes after instillation. It increases ocular contact time and dramatically reduces systemic absorption through the nasolacrimal duct — which is the whole reason an eye drop can drop a heart rate.

Triage scorecard

What you taught before they went home

Protective shield at night, sunglasses in daylight, sleep on the non-operative side, do not rub or press the eye.
No bending at the waist, no lifting more than about ten pounds, no straining at stool — a stool softener is a legitimate nursing suggestion — and no vigorous coughing or vomiting for the period ordered.
Expected: mild scratchiness, itching, a bloodshot appearance.
Not expected: increasing pain, decreasing vision, a sudden shower of floaters or flashing lights, purulent discharge. Those mean endophthalmitis or retinal detachment and require the surgeon the same hour.