But if the pressure remains dangerously elevated, I don’t keep waiting.
💉 I perform an anterior chamber paracentesis at the slit lamp.
This allows me to rapidly decompress the eye, immediately lower the IOP, and often provide significant symptomatic relief.
Why not pilocarpine?
At extremely high IOPs, the iris sphincter becomes ischemic, making pilocarpine relatively ineffective. Additionally, pilocarpine can cause anterior rotation of the ciliary body and forward displacement of the lens–iris diaphragm, potentially worsening angle crowding in certain mechanisms of angle closure.
Why not go straight to LPI?
During an acute attack, the eye is often extremely inflamed, with significant corneal edema that makes laser visualization challenging.
Additionally, longstanding or severe angle closure may already have resulted in significant peripheral anterior synechiae (PAS), which an LPI will not reverse.
Does this mean I never perform an LPI? Absolutely not!
LPI remains an important definitive treatment when pupillary block is the underlying mechanism. I just prefer to stabilize the eye and lower the pressure first when visualization is poor.
⚠️ An AC paracentesis is a temporizing intervention, not definitive treatment, and requires careful patient selection.
13 days agorogier_muller
Doesn't a paracentesis risk shallowing the anterior chamber and making the situation worse?
18 days agoananazaljawi
Been there, done that! Have you encountered any iris tending to prolapse through the wound during the procedure? If yes how would you avoid it ? ((Shallow AC and very high IOP))
21 days agosilvia.vivienne
My personal rule is never do anything to a patient where the potential complication cannot also be handled by you. So, if you are willing to take care of a traumatic cataract or worse, a suprachoroidal hemorrhage from rapid IOP decompression, then, yes do the AC tap.
22 days agotuang_baby
I’m still trying to understand the rationale behind pushing the boundaries of what can be done at the slit lamp. Does it meaningfully improve patient outcome? Is the risk–benefit ratio truly justified? Even a procedure as simple as suture removal on the slit lamp carries a risk of endoph and here you are, willing to sacrifice it all for some fancy reel on social media.
22 days agodr_lucas_machado
I always really wanted to do it in those situations, but i never worked up the courage. It makes a lot of sense.
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