Download MBBS Ophthalmology PPT 45 Primary Angle Closure Glaucoma 2 Lecture Notes

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GLAUCOMA

Acknowledgement

? Kanski's Clinical Ophthalmology (8th Edition).

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? Becker- Schaffer's Diagnosis and therapy of

The Glaucomas (8th Edition).

? Comprehensive Ophthalmology (A.K.Khurana)

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(7th Edition).

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Learning Objectives

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? At the end of this class the students shal be able

to :

? Define primary angle closure glaucoma.

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? Understand the pathophysiology and the risk

factors.

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? Be able to classify primary angle closure

glaucoma.

? Understand the fundamentals of managing

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primary angle closure glaucoma

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Question

? Which of the following medications is least

likely to be associated with the induction or

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aggravation of angle-closure glaucoma?

? a. pilocarpine.
? b. oral antihistamines.

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? c. cyclopentolate.
? d. aspirin

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DEFINITION

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? Primary angle closure glaucoma is a type of

primary glaucoma(with no obvious systemic or

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ocular cause) characterized by

occludable/closed angles leading to

obstruction of aqueous outflow resulting in

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rise of intra ocular pressure, optic nerve

damage and visual field defects.

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Video on applanation tonometry

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ANGLE OF ANTERIOR CHAMBER

? STRUCTURES

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? Schwalbe's line
? Trabecular meshwork
? Scleral spur
? Ciliary body band

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? Root of iris

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DRAINAGE OF AQUEOUS HUMOR

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PRIMARY ANGLE CLOSURE

GLAUCOMA

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EPIDEMIOLOGY
? PACG is the major cause of glaucoma blindness

worldwide.

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? Age :- Average age at presentation 50-60 yrs
? Gender :- F > M, 4 : 1
? Race :-seen commonly in South-East Asian

population, Chinese and Eskimos

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? Heredity :- Mostly sporadic
? Refractive error :- more common in hypermetropes

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Ocular risk factors

1. Shallow anterior chamber both

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centrally and peripherally.

2. Decreased anterior chamber

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volume.

3. Short axial length of the globe.

4. Small corneal diameter.

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Ocular risk factors

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5.Decreased posterior corneal radius of

curvature

6.Anterior position of the lens with respect to

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the ciliary body.

7.Increased curvature of the anterior surface &

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thickness of lens

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PATHOGENESIS

? It is incompletely understood.

? a. Iris?pupil obstruction (e.g., `pupil ary block')

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? b. Ciliary body anomalies (e.g., `plateau iris syndrome')
? c. Lens?pupil block (e.g., `phacomorphic block' (swollen

lens or microspherophakia))

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? Relative Pupillary block
? Normal y the pressure in the post. chamber exceeds that in the anterior

chamber due to physiological degree of resistance at the pupil ,since the

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iris rests posteriorly on the anterior lens capsule.

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Anterior Iris Bowing

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Simultaneous dilatation of the pupil renders the peripheral

iris more flaccid. The pupil block causes the pressure in the

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Posterior Chamber to increase & peripheral iris bows

anteriorly

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Iridocorneal contact

Eventually the iris touches the posterior corneal surface,

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obstructing the angle and the IOP rises.

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Precipitating factors

Factors that produce mydriasis

? Dim illumination

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? Emotional stress(due to increased sympathetic tone)
? Drugs

? Mydriatic agents :

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? cyclopentolate, tropicamide, atropine, homatropine.

? Antipsychotic agents

? Phenothiazines: e.g., perphenazine ,fluphenazine

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? Anticonvulsants e.g., Topiramate

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? Antidepressants

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? Tricyclic agents: amitriptylene ,imipramine
? Non-tricyclic agents: fluoxetine

? Antiparkinsonian agents : Trihexyphenidryl

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? Antispasmolytics : Propantheline ,Dicyclomine

? Sympathomimetic agents : Adrenaline (epinephrine),

ephedrine, phenylephrine.

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CLASSIFICATION

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A. Primary angle-closure disease

? Irido-trabecular contact is the final common pathway of

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angle closure disease, obstructing aqueous outflow

1. New classification
Primary angle closure suspect/PACS
Primary angle closure/PAC

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Primary angle-closure glaucoma/PACG
2. Old classification

Angle closure suspect
Intermittent (sub acute) angle closure

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Acute angle closure
Chronic angle closure
Absolute angle closure

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New classification of PACG

qPrimary angle closure suspect/PACS

Has occludable/narrow angles

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qPrimary angle closure/PAC

Has occludable/narrow angles +

High IOP/Peripheral anterior synechiae/

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Excessive trabecular meshwork

pigmentation
qPrimary angle-closure glaucoma/PACG

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PAC+ Optic disc changes+ Visual field

defects

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Gonioscopic grading of Angle

closure

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? Several grading systems :- Shaffer's, Spaeth's,

Scheie's.

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? Shaffer's grading

Grade Angle width configuration

Chances of

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Structures visible

closure

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IV

35?-45?

Wide open

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Nil

SL,TM,SS,CBB

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I I

20?-35?

Open angle

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Nil

SL,TM,SS

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I

20?

Moderately open Possible

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SL,TM

I

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10?

Very narrow

Highly likely

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SL only

0

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0?

Closed

Closed

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None

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---------
Grade
IV

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II

II

I

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0

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Van Herrick's grading

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Tests for Angle closure

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? Eclipse test : uses flash light to make a rough

assessment of angle depth

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? Provocative tests for PAC suspects
?Prone- darkroom test: An increase in IOP of more

than 8mm Hg after one hour suggests PAC

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qFincham's Test: Also known as stenopaeic-slit test.

Glaucomatous halos remain intact , whereas

halos due to cataract are broken up into segments

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PRIMARY ANGLE CLOSURE GLAUCOMA SUSPECT

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? Also known as Latent PACG
? Essentially, the term implies

an anatomically predisposed

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eye.

? Symptoms :- absent
? Signs :

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? Axial AC depth is < normal

& iris lens diaphragm is

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convex

? Close proximity of the iris

to the cornea

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? Gonioscopy :- occludable

angle(grade 1 or 0)

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without indentation in at

least 3 quadrants.

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?Clinical course without

treatment may be:

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IOP may remain normal

Acute or sub acute angle

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closure may ensue

Chronic angle closure may

develop, without acute or

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sub acute stages.

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? Treatment
? Without treatment , risk of an acute pressure rise during the next

5 years is about 50 %.

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? The need to treat is based on following criteria:-

? If one eye has had acute or subacute angle closure, then

fellow eye should undergo prophylactic peripheral laser

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iridotomy (Laser PI)

? If both eyes have occludable angles, laser PI may be done

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INTERMITTENT(SUBACUTE)PRIMARY ANGLE CLOSURE

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GLAUCOMA

? A form of pupillary block glaucoma, which may not have

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any recognizable symptoms.

? Occurs in a predisposed eye with an occludable angle in

association with intermittent pupillary block.

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? Precipitating factors :- physiological mydriasis , or

physiological shallowing of AC when patient assumes a
prone or semi prone position ;emotional stress.

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INTERMITTENT(SUBACUTE)PRIMARY ANGLE

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CLOSURE GLAUCOMA

? Symptoms

? Characteristic h/o transient blurring of vision with haloes

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around lights

? Ocular discomfort or frontal headache
? Attacks are recurrent and are usually broken after 1-2 hrs

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by physiological miosis.

? Signs

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? During an attack , eye is usually white
? In between attacks, eye looks normal although the angle is

narrow.

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INTERMITTENT(SUBACUTE)PRIMARY ANGLE

CLOSURE GLAUCOMA

? Clinical course

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? Without treatment is variable

? Some eyes develop an acute attack
? Others chronic angle closure

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? Treatment:- Prophylactic laser PeripheraI Iridotomy(PI)

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ACUTE PRIMARY ANGLE CLOSURE GLAUCOMA

? Sight threatening emergency
? Painful loss of vision due to sudden and total

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closure of the angle.

? VA usually 6/60-Hand Movements.
? IOP is usually very high (40?70 mmHg).

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Findings during an acute attack of angle-closure glaucoma
? Two of the following symptom sets:

? Periorbital or ocular pain

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? Diminished vision
? Specific history of rainbow haloes with blurred vision

? IOP > 21 mmHg plus three of the following

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findings:

? Ciliary flush (perilimbal conjunctival hyperemia)
? Corneal edema (epithelial,stromal)
? Shallow anterior chamber

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Findings during an acute attack of angle-closure glaucoma

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? Anterior chamber cell and flare
? Mid-dilated ,vertically oval and sluggishly reactive

pupil

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? Closed angle on gonioscopy
? Hyperemic and swollen optic disc(due to

decreased axoplasmic outflow)

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? Constricted visual fields

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? MANAGEMENT

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? Patient comfort ,lowering of the IOP and to break acute

attack-- main priorities.

? A. Immediate medical treatment

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1. Patient should lie supine to allow the lens to shift

posteriorly.

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2. Acetazolamide 500 mg orally(if there is no vomiting).

or I.V Mannitol 20% 1-2 g/kg over 1 hour (rule out

contraindications)

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3.Topical

Prednisolone or dexamethasone q.i.d (if AC reaction)

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Timolol (if there is no contraindication).

4. Analgesia and emetics as required.

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? B. Subsequent medical treatment

Pilocarpine 2% q.i.d. to the affected eye and 1% q.i.d. to the

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fellow eye.

Topical steroids (prednisolone 1% or dexamethasone 0.1%)

q.i.d. if the eye is acutely inflamed.

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Timolol 0.5% b.d.,

and oral acetazolamide 250 mg q.i.d. may be required.

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? If the above measures fail:

? Laser iridotomy or iridoplasty after clearing corneal oedema with

glycerol.

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? Surgery in resistant cases.

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? Findings suggestive of previous episodes of acute

angle closure glaucoma

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? Fine pigment granules on corneal endothelium
? Peripheral anterior synechiae
? Posterior synechiae
? Glaucomflecken
? Sectoral/generalized iris atrophy

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? Fixed and semi dilated pupil

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Findings suggestive of previous episodes of

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acute angle closure glaucoma

? Optic nerve cupping &/or pallor
? Gonioscopy shows narrow angle or PAS

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? Visual field loss

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Chronic angle closure glaucoma

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? Visual Acuity is normal unless damage is

advanced.

? Anterior chamber is shal ower in pupil ary block

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than non-pupil ary block.

? Optic nerve signs depend on severity of damage.
? IOP elevation may be only intermittent.

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? Gonioscopic abnormalities-
Peripheral Anterior Synechiae, narrow angle,
pigmentation of Schwalbe's line.

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Treatment of chronic angle closure

? Medical treatment is similar to that of POAG
? Prostaglandin/Prostamides

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Latanoprost, Bimatoprost, Travoprost
? Beta blockers
Timolol maleate, Betaxolol
? Carbonic anhydrase inhibitors
Dorzolamide, Brinzolamide

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Treatment of chronic angle closure

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? Sympathomimetics
Brimonidine, Apraclonidine
? Parasmpathomimetics
Pilocarpine

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? Oral carbonic anhydrase inhibitors
Acetazolamide, Methazolamide

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Treatment of chronic angle closure

? Laser Peripheral Iridotomy (PI) in affected eye

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along with Prophylactic PI in fellow eye

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Laser Peripheral Iridotomy

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? Complications of laser therapy
1. Bleeding
2. IOP elevation
3. Iritis
4. Corneal burns

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5. Lens opacities
6. Glare and diplopia

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? Surgical treatment

Trabeculectomy (filtering surgery) is the

surgical procedure of choice

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? Success:- 87- 100 % with multiple operations

? Complications:-

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? Flat AC, hypotony

? Bleb related infections

? Cyclodialysis

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? PATIENTS REQUIRE REGULAR AND LIFE LONG

FOLLOW UP

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Absolute glaucoma

? Is the final/last stage of PACG
? Clinical features:

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? Painful blind eye
?Perilimbal reddish blue zone, due to dilated

anterior ciliary veins

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?Cornea gradually becomes hazy, insensitive

with bullous keratopathy

?Anterior chamber is very shallow/flat

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Clinical features of absolute glaucoma

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? Iris is usually atrophic

?Pupil is fixed and dilated

?Glaucomatous optic atrophy of the optic disc

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?High IOP

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Management of absolute glaucoma

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? Cycloablation/destruction of the secretory

ciliary epithelium

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q Cyclophotocoagulation
q Cyclocryotherapy
q Cyclodiathermy
? Rarely
? Retrobulbar alcohol injection

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? Enucleation of eyeball

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Complications

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? Corneal ulceration
? Staphyloma formation (Ciliary/Equatorial)
? Atrophic bulbi (Shrunken eye)

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Conclusion

? Primary angle closure glaucoma is a

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potentially sight threatening condition,

characterized by occludable anterior chamber

angles.

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? Obstruction of aqueous outflow results in rise

of intra ocular pressure, optic nerve damage

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and visual field defects.

? Management may include medical, laser

and/or surgical modalities.

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Question

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? Primary angle closure glaucoma occurs most

commonly in patients with shallow anterior

chambers. Among the following, which does

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NOT contribute to a shallow anterior

chamber?

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? A) Mature lens

? B) Hyperopia

? C) Ocular hypertension

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? D) Iris bomb?

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Question

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? With respect to angle-closure glaucoma, which of the

fol owing is true?

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? a. Men are at increased risk.
? b. The anterior chamber depth increases with age,

predisposing to pupillary-block- induced angle-closure

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glaucoma.

? c. Primary angle-closure glaucoma may occur in eyes with

any type of refractive error.

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? d. Family history, while important in open-angle glaucoma,

does not play a role in angle-closure glaucoma.

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