Angle Closure Glaucoma

CLASSIFICATION

Angle-Closure Glaucoma

Primary

Acute (AACG)

Chronic (CACG)

Secondary

Neovascular/ Inflammatory/ Iridocorneal endothelial

(ICE) syndrome

DEFINITION

• Closed-angle glaucomas are characterized by a shallow anterior chamber that forces the root of the mid-dilated iris forward against the trabecular network, obstructing the drainage of aqueous humor and thereby increasing the intraocular pressure.

Groups at Risks

1. Age >60 years

2. Gender: females > males (4:1)

3. Race: Asians

4. Family history: increased risk with 1st degree relatives

PREDISPOSING FACTORS

Anatomical

• Relative anterior position of iris-lens diaphragm• Shallow anterior chamber• Narrow entrance to angle

Physiological

• Physiological pupillary block

PHYSIOLOGICAL PUPILLARY BLOCK1. Iris has large arc of contact with anterior surface of lens

2. Resistance to aqueous flow from posterior to anterior chamber (relative pupil block)

3. Pupil dilates, peripheral iris becomes more flaccid and pushed anteriorly

4. Iris lies against trabecular meshwork impede aqueous humor drainage ↑ IOP

SYMPTOMS1. Rapidly progressive impairment of vision

2. Painful eye

3. Red eye

4. Nausea, vomiting

5. Photophobia

6. Haloes, transient blurring – indicate previous intermittent attacks

7. Hx of similar attacks in the past, aborted by sleep

** CACG: usually asymptomatic due to slow onset of disease

SIGNS1. Reduced visual acuity

2. Cornea cloudy and oedematous

3. Pupil oval, fixed and moderately dilated

4. Ciliary injection

5. Eye feels hard on palpation

6. Elevated IOP (50-100 mmHg)

7. Narrow chamber angle with peripheral iridocorneal contact

8. Aqueous flare and cells

9. Gonioscopy – complete peripheral iridocorneal contact

10. Ophthalmoscopy – optic disc odema and hyperaemia

ACUTE CONGESTIVE ANGLE CLOSURE GLAUCOMA

• Due to rapid ↑ in IOP• Defined as:

At least 2 of the following

SYMPTOMS:

•Ocular pain•Nausea/ vomiting•Hx of intermittent BOV with halos

Plus 3 of the following SIGNS•IOP > 21mmHg•Conjunctival injection•Corneal epithelial edema•Mid-dilated non reactive pupil•Shallower chamber in presence of occlusion

Severe edematous cornea, Dilated,

unreactive,vertically oval pupil

Ciliary injection, Shallow anterior

chamber

Complete angle closure

DIFFERENTIAL DIAGNOSIS

Usually blurred

Markedly blurred

Slightly blurred

No effect on vision

Vision

Moderate to severe

SevereModeratevariablePain

Watery or purulent

NoneNoneModerate to copious (mucopurulent)

Discharge

CommonUncommonCommonExtremely common

Incidence

Corneal trauma or infection

Acute congestive glaucoma

Acute iridocycliti

s

Acute conjunctiv

itis

Organisms found only in corneal ulcers due to infection

No organismsNo organismsCausative organisms

Smear

NormalElevatedNormalNormalIntraocular pressure

NormalNonePoorNormalPupillary light response

NormalSemidilated and fixed

SmallNormal Pupil size

Change in clarity related to cause

HazyUsually clearClearCornea

DiffuseDiffuseMainly circumcorneal

Diffuse, more toward fornices

Conjunctival injection

MANAGEMENT

– Prevent adhesions of peripheral iris to trabecular meshwork resulting in permanent closure of angle

1. I.V acetazolamide 500mg followed by oral acetazolamide 250mg qid after acute attack has broken

2. Topical beta-blockers3. Topical steriods four times daily to lower the intraocular

pressure and decongest the eye

Emergency treatment is required – preserve the sight!

Reassessment•Evaluate IOP•Evaluate adjunct drops•May need osmotic agents? Immediate iridotomy?

Approx 1 hr after initial RX

•Start with Pilocarpine (myotic drug) every 15mins x 2 doses

SURGICAL MANAGEMENT

1. Peripheral laser iridotomy (LPI)

(YAG Laser)– To establish the communication between the posterior and anterior

chambers by making an opening in the peripheral iris– This will be successful only if less than 50% of the angle is closed by

permanent peripheral anterior synechiae

2. Peripheral Iridectomy

CX AND SEQUALAE

1. Peripheral anterior synechiae (PAS) – the peripheral iris adheres to the posterior corneal surface in the trabecular area and blocks the outflow of aqueous

2. Cataract- swelling of the lens and cataract formation – this may push the iris even further anteriorly; this increases the pupillary block

3. Atrophy of the retina and optic nerve - glaucomatous cupping of the optic disc and retinal atrophy

4. Absolute glaucoma - eye is stony hard, sightless, painful

SECONDARY ANGLE CLOSURE GLAUCOMA

• Angle-closure secondary to a variety of ocular disorders– Lens abnormalities (thick cataract)– Lens dislocation– Inflammation (uveitis, scleritis, extensive retinal

photocoagulation)• Signs and symptoms – Same as PACG

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