Systemic Medications as Triggers of Acute Angle-Closure Glaucoma: A Narrative Review

Background: Acute angle-closure glaucoma (AACG) is an emergency requiring rapid intervention to prevent irreversible optic nerve damage and permanent vision loss. Methods: This narrative review synthesizes the systemic medication classes most implicated in medication-induced AACG, outlining their underlying pathophysiological mechanisms, typical timing of onset, and practical risk-reduction strategies. Evidence was collected through targeted searches of the PubMed, Google Scholar, Cochrane Library, and Web of Science databases, focusing on major review articles, pharmacoepidemiologic studies, and clinical consensus guidelines. Source selection and data synthesis followed a narrative approach without formal risk of bias assessment or meta-analysis. Results: The literature consistently implicates sulfonamide derivatives (mainly topiramate), serotonergic antidepressants and triptans, potent systemic anticholinergics, and adrenergic decongestants. Sulfonamides typically precipitate bilateral, non-pupillary-block AACG via ciliochoroidal effusion, secondary anterior displacement of the lens-iris diaphragm, and an acute myopic shift. Conversely, serotonergic, anticholinergic, and adrenergic agents typically trigger classic pupillary-block AACG in anatomically predisposed eyes with pre-existing narrow angles. Adverse events predominantly occur shortly after treatment initiation or dose escalation. Management relies on prompt medication discontinuation and rapid intraocular pressure reduction. Importantly, cycloplegics are preferred over miotics in effusion-induced cases. Given the rarity of these events, brief patient education represents a pragmatic and scalable approach, although its direct clinical effectiveness in reducing event rates has not yet been formally established. Conclusions: A select group of widely prescribed systemic medications are associated with most cases of medication-induced AACG. Improving clinician awareness, providing brief patient counseling on warning symptoms, and ensuring prompt ophthalmic evaluation represent the most practical currently available risk-reduction strategies to prevent vision loss.