In acute angle-closure glaucoma, which topical medication is most appropriate after systemic therapy?

• A. Brimonidine 0.2% ophthalmic solution
• B. Glycerin PO 2 g/kg
• C. Pilocarpine 4% ophthalmic solution
• D. Acetazolamide IV

Answer: (C)

Acute angle-closure glaucoma starts with a pupillary block that closes the angle and rapidly raises intraocular pressure. The immediate goal is to lower pressure systemically first, which reduces iris ischemia and corneal edema, making subsequent steps more effective. Once the IOP has fallen enough and the iris is no longer constricted by high pressure, a topical miotic is used to open the angle. Pilocarpine 4% works best at this stage because it contracts the ciliary muscle and causes miosis, pulling the peripheral iris away from the trabecular meshwork and widening the angle to improve outflow. This combination—systemic pressure reduction followed by topical pilocarpine—addresses both the pressure and the block, making pilocarpine the ideal topical choice after systemic therapy. Brimonidine can lower IOP but doesn’t reliably open the blocked angle; glycerin and acetazolamide can be systemic options for lowering pressure but aren’t topical agents.