PRIMARY ANGLE CLOSURE
--- Content provided by FirstRanker.com ---
GLAUCOMAAcknowledgement
? Figures and photographs
--- Content provided by FirstRanker.com ---
Courtesy : Kanski's Clinical Ophthalmology2
Learning Objectives
--- Content provided by FirstRanker.com ---
? At the end of this class the students shal be ableto :
? Define primary angle closure glaucoma.
--- Content provided by FirstRanker.com ---
? Understand the pathophysiology and the risk
factors.
--- Content provided by FirstRanker.com ---
? Be able to classify primary angle closureglaucoma.
? Understand the fundamentals of managing
--- Content provided by FirstRanker.com ---
primary angle closure glaucoma
3
--- Content provided by FirstRanker.com ---
DEFINITION? Primary angle closure glaucoma is a type of
primary glaucoma(with no obvious systemic or
--- Content provided by FirstRanker.com ---
ocular cause) characterized by
occludable/closed angles leading to
--- Content provided by FirstRanker.com ---
obstruction of aqueous outflow resulting inrise of intra ocular pressure, optic nerve
damage and visual field defects.
--- Content provided by FirstRanker.com ---
4
ANGLE OF ANTERIOR CHAMBER
--- Content provided by FirstRanker.com ---
? STRUCTURES
? Schwalbe's line
? Trabecular meshwork
--- Content provided by FirstRanker.com ---
? Scleral spur? Ciliary body band
? Root of iris
5
--- Content provided by FirstRanker.com ---
DRAINAGE OF AQUEOUS HUMOR
6
--- Content provided by FirstRanker.com ---
PRIMARY ANGLE CLOSURE
GLAUCOMA
--- Content provided by FirstRanker.com ---
EPIDEMIOLOGY? PACG is the major cause of glaucoma blindness
worldwide.
--- Content provided by FirstRanker.com ---
? Age :- Average age at presentation 50-60 yrs
? Gender :- F > M, 4 : 1
--- Content provided by FirstRanker.com ---
? Race :-seen commonly in South-East Asianpopulation, Chinese and Eskimos
? Heredity :- mostly sporadic but may be inherited
--- Content provided by FirstRanker.com ---
AD/AR
? first degree relatives are at increased risk.
--- Content provided by FirstRanker.com ---
? Refractive error :- more common inhypermetropes
7
--- Content provided by FirstRanker.com ---
Ocular risk factors
1. Shallow anterior chamber both
--- Content provided by FirstRanker.com ---
centrally and peripherally.2. Decreased anterior chamber volume.
3. Short axial length of the globe.
--- Content provided by FirstRanker.com ---
4. Small corneal diameter.
8
--- Content provided by FirstRanker.com ---
Ocular risk factors
5.Decreased posterior corneal radius of
--- Content provided by FirstRanker.com ---
curvature6.Anterior position of the lens with respect to
the ciliary body.
--- Content provided by FirstRanker.com ---
7.Increased curvature of the anterior surface &
thickness of lens
--- Content provided by FirstRanker.com ---
9PATHOGENESIS
? It is incompletely understood.
--- Content provided by FirstRanker.com ---
? a. Iris?pupil obstruction (e.g., `pupil ary block')
? b. Ciliary body anomalies (e.g., `plateau iris syndrome')
? c. Lens?pupil block (e.g., `phacomorphic block' (swollen
--- Content provided by FirstRanker.com ---
lens or microspherophakia))? Relative Pupillary block
? Normal y the pressure in the post. chamber exceeds that in the ant.
--- Content provided by FirstRanker.com ---
chamber due to physiological degree of resistance at the pupil ,since theiris rests posteriorly on the anterior lens capsule.
10
--- Content provided by FirstRanker.com ---
Anterior Iris Bowing
Simultaneous dilatation of the pupil renders the peripheral
--- Content provided by FirstRanker.com ---
iris more flaccid. The pupil block causes the pressure in the
Posterior Chamber to increase & peripheral iris bows
--- Content provided by FirstRanker.com ---
anteriorly11
Iridocorneal contact
--- Content provided by FirstRanker.com ---
Eventually the iris touches the posterior corneal surface,
obstructing the angle and the IOP rises.
--- Content provided by FirstRanker.com ---
12Precipitating factors
1. Factors that produce mydriasis
--- Content provided by FirstRanker.com ---
? Dim illumination? Emotional stress(due to increased sympathetic tone)
? Drugs
? Mydriatic agents :
--- Content provided by FirstRanker.com ---
? cyclopentolate, tropicamide, atropine, homatropine.
? Antipsychotic agents
--- Content provided by FirstRanker.com ---
? Phenothiazines: e.g., perphenazine ,fluphenazine? Anticonvulsants e.g., Topiramate
13
--- Content provided by FirstRanker.com ---
? Antidepressants? Tricyclic agents: amitriptylene ,imipramine
? Non-tricyclic agents: fluoxetine
--- Content provided by FirstRanker.com ---
? Antiparkinsonian agents : Trihexyphenidryl? Antispasmolytics : Propantheline ,Dicyclomine
? Sympathomimetic agents : Adrenaline (epinephrine),
--- Content provided by FirstRanker.com ---
ephedrine, phenylephrine.
14
--- Content provided by FirstRanker.com ---
CLASSIFICATIONA. Primary angle-closure disease
? Irido-trabecular contact is the final common pathway of
--- Content provided by FirstRanker.com ---
angle closure disease, obstructing aqueous outflow
1. New classification
Primary angle closure suspect/PACS
--- Content provided by FirstRanker.com ---
Primary angle closure/PACPrimary angle-closure glaucoma/PACG
2. Old classification
Angle closure suspect
--- Content provided by FirstRanker.com ---
Intermittent (sub acute) angle closureAcute angle closure
Chronic angle closure
Absolute angle closure
--- Content provided by FirstRanker.com ---
15New classification of PACG
qPrimary angle closure suspect/PACS
--- Content provided by FirstRanker.com ---
Has occludable/narrow angles
qPrimary angle closure/PAC
Has occludable/narrow angles +
--- Content provided by FirstRanker.com ---
High IOP/Peripheral anterior synechiae/
Excessive trabecular meshwork
--- Content provided by FirstRanker.com ---
pigmentationqPrimary angle-closure glaucoma/PACG
PAC+ Optic disc changes+ Visual field
--- Content provided by FirstRanker.com ---
defects16
Gonioscopic grading of Angle
--- Content provided by FirstRanker.com ---
closure? Several grading systems :- Shaffer's, Spaeth's,
Scheie's.
--- Content provided by FirstRanker.com ---
? Shaffer's grading
Grade Angle width configuration
--- Content provided by FirstRanker.com ---
Chances ofStructures visible
closure
--- Content provided by FirstRanker.com ---
IV
35?-45?
--- Content provided by FirstRanker.com ---
Wide openNil
SL,TM,SS,CBB
--- Content provided by FirstRanker.com ---
I I
20?-35?
--- Content provided by FirstRanker.com ---
Open angleNil
SL,TM,SS
--- Content provided by FirstRanker.com ---
I
20?
--- Content provided by FirstRanker.com ---
Moderately open PossibleSL,TM
I
--- Content provided by FirstRanker.com ---
10?
Very narrow
--- Content provided by FirstRanker.com ---
Highly likelySL only
0
--- Content provided by FirstRanker.com ---
0?
Closed
--- Content provided by FirstRanker.com ---
ClosedNone
17
--- Content provided by FirstRanker.com ---
---------
Grade
IV
--- Content provided by FirstRanker.com ---
IIII
I
--- Content provided by FirstRanker.com ---
018
--- Content provided by FirstRanker.com ---
Van Herrick's grading19
Tests for Angle closure
--- Content provided by FirstRanker.com ---
? Eclipse test : uses flash light to make a rough
assessment of angle depth
--- Content provided by FirstRanker.com ---
? Provocative tests for PAC suspects?Prone- darkroom test: An increase in IOP of more
than 8mm Hg after one hour suggests PAC
--- Content provided by FirstRanker.com ---
?Mydriatic provocative test: Not preferred nowqFincham's Test: Also known as stenopaeic-slit test.
Glaucomatous halos remain intact , whereas
--- Content provided by FirstRanker.com ---
halos due to cataract are broken up into segments
--- Content provided by FirstRanker.com ---
20--- Content provided by FirstRanker.com ---
PRIMARY ANGLE CLOSURE GLAUCOMA SUSPECT? Also known as Latent PACG
? Essentially, the term implies
--- Content provided by FirstRanker.com ---
an anatomically predisposedeye.
? Symptoms :- absent
--- Content provided by FirstRanker.com ---
? Signs :? Axial AC depth is < normal
& iris lens diaphragm is
--- Content provided by FirstRanker.com ---
convex
? Close proximity of the iris
--- Content provided by FirstRanker.com ---
to the cornea? Gonioscopy :- occludable
angle(grade 1 or 0)
--- Content provided by FirstRanker.com ---
without indentation in at
least 3 quadrants.
--- Content provided by FirstRanker.com ---
21?Clinical course without
treatment may be:
--- Content provided by FirstRanker.com ---
IOP may remain normal
Acute or sub acute angle
--- Content provided by FirstRanker.com ---
closure may ensueChronic angle closure may
develop, without acute or
--- Content provided by FirstRanker.com ---
sub acute stages.
22
--- Content provided by FirstRanker.com ---
? Treatment
? Without treatment , risk of an acute pressure rise during the next
5 years is about 50 %.
--- Content provided by FirstRanker.com ---
? The need to treat is based on following criteria:-
? If one eye has had acute or subacute angle closure, then
--- Content provided by FirstRanker.com ---
fellow eye should undergo prophylactic peripheral laseriridotomy (Laser PI)
? If both eyes have occludable angles, laser PI may be done
--- Content provided by FirstRanker.com ---
23INTERMITTENT(SUBACUTE)PRIMARY ANGLE CLOSURE
GLAUCOMA
--- Content provided by FirstRanker.com ---
? A form of pupillary block glaucoma, which may not have
any recognizable symptoms.
--- Content provided by FirstRanker.com ---
? Occurs in a predisposed eye with an occludable angle inassociation with intermittent pupillary block.
? Precipitating factors :- physiological mydriasis , or
--- Content provided by FirstRanker.com ---
physiological shallowing of AC when patient assumes a
prone or semi prone position ;emotional stress.
--- Content provided by FirstRanker.com ---
24? Symptoms
--- Content provided by FirstRanker.com ---
? Characteristic h/o transient blurring of vision with haloesaround lights
? Ocular discomfort or frontal headache
--- Content provided by FirstRanker.com ---
? Attacks are recurrent and are usually broken after 1-2 hrs byphysiological miosis.
? Signs
--- Content provided by FirstRanker.com ---
? During an attack , eye is usually white
? In between attacks, eye looks normal although the angle is
narrow.
--- Content provided by FirstRanker.com ---
? Clinical course
? Without treatment is variable
--- Content provided by FirstRanker.com ---
? Some eyes develop an acute attack? Others chronic angle closure
? Treatment:- Prophylactic laser PeripheraI Iridotomy(PI)
--- Content provided by FirstRanker.com ---
25ACUTE PRIMARY ANGLE CLOSURE GLAUCOMA
? Sight threatening emergency
--- Content provided by FirstRanker.com ---
? Painful loss of vision due to sudden and totalclosure of the angle.
? VA usually 6/60-Hand Movements.
--- Content provided by FirstRanker.com ---
? IOP is usually very high (40?70 mmHg).26
Findings during an acute attack of angle-closure glaucoma
? Two of the following symptom sets:
--- Content provided by FirstRanker.com ---
? Periorbital or ocular pain
? Diminished vision
? Specific history of rainbow haloes with blurred vision
--- Content provided by FirstRanker.com ---
? IOP > 21 mmHg plus three of the followingfindings:
? Ciliary flush (perilimbal conjunctival hyperemia)
--- Content provided by FirstRanker.com ---
? Corneal edema (epithelial,stromal)? Shallow anterior chamber
27
--- Content provided by FirstRanker.com ---
Findings during an acute attack of angle-closure glaucoma? Anterior chamber cell and flare
? Mid-dilated ,vertically oval and sluggishly reactive
--- Content provided by FirstRanker.com ---
pupil? Closed angle on gonioscopy
? Hyperemic and swollen optic disc(due to
--- Content provided by FirstRanker.com ---
decreased axoplasmic outflow)? Constricted visual fields
28
--- Content provided by FirstRanker.com ---
? MANAGEMENT? Patient comfort ,lowering of the IOP and to break acute
attack-- main priorities.
--- Content provided by FirstRanker.com ---
? A. Immediate medical treatment
1. Patient should lie supine to allow the lens to shift
--- Content provided by FirstRanker.com ---
posteriorly.2. Acetazolamide 500 mg orally(if there is no vomiting).
or I.V Mannitol 20% 1-2 g/kg over 1 hour (rule out
--- Content provided by FirstRanker.com ---
contraindications)
3.Topical
--- Content provided by FirstRanker.com ---
Prednisolone or dexamethasone q.i.d (if AC reaction)Timolol (if there is no contraindication).
4. Analgesia and emetics as required.
--- Content provided by FirstRanker.com ---
29
? B. Subsequent medical treatment
--- Content provided by FirstRanker.com ---
Pilocarpine 2% q.i.d. to the affected eye and 1% q.i.d. to thefellow eye.
Topical steroids (prednisolone 1% or dexamethasone 0.1%)
--- Content provided by FirstRanker.com ---
q.i.d. if the eye is acutely inflamed.
Timolol 0.5% b.d.,
--- Content provided by FirstRanker.com ---
and oral acetazolamide 250 mg q.i.d. may be required.? If the above measures fail:
? Laser iridotomy or iridoplasty after clearing corneal oedema with
--- Content provided by FirstRanker.com ---
glycerol.
? Surgical options in resistant cases include lens extraction,
--- Content provided by FirstRanker.com ---
goniosynechiolysis, trabeculectomy and cycloablation.30
--- Content provided by FirstRanker.com ---
? Findings suggestive of previous episodes of acuteangle closure glaucoma
? Descemets Membrane folds
--- Content provided by FirstRanker.com ---
? Fine pigment granules on corneal endothelium
? Peripheral anterior synechiae
--- Content provided by FirstRanker.com ---
? Posterior synechiae? Glaucomflecken
? Sectoral/generalized iris atrophy
--- Content provided by FirstRanker.com ---
? Fixed and semi dilated pupil
? Optic nerve cupping &/or pallor
--- Content provided by FirstRanker.com ---
? Gonioscopy shows narrow angleor PAS
? Visual field loss
--- Content provided by FirstRanker.com ---
31
Chronic angle closure glaucoma
--- Content provided by FirstRanker.com ---
? Visual Acuity is normal unless damage isadvanced.
? Anterior chamber is shal ower in pupil ary
--- Content provided by FirstRanker.com ---
block than non-pupil ary block.
? Optic nerve signs depend on severity of
--- Content provided by FirstRanker.com ---
damage.? IOP elevation may be only intermittent.
? Gonioscopic abnormalities-Peripheral
--- Content provided by FirstRanker.com ---
Anterior Synechiae, narrow angle,
pigmentation of Schwalbe's line.
--- Content provided by FirstRanker.com ---
32Treatment of chronic angle closure
--- Content provided by FirstRanker.com ---
? Medical treatment is similar to that of POAG? Prostaglandin/Prostamides
Latanoprost, Bimatoprost, Travoprost
--- Content provided by FirstRanker.com ---
? Beta blockers
Timolol maleate, Betaxolol
--- Content provided by FirstRanker.com ---
? Carbonic anhydrase inhibitorsDorzolamide, Brinzolamide
? Sympathomimetics
--- Content provided by FirstRanker.com ---
Brimonidine, Apraclonidine
? Parasmpathomimetics
--- Content provided by FirstRanker.com ---
Pilocarpine? Oral carbonic anhydrase inhibitors
Acetazolamide, Methazolamide
--- Content provided by FirstRanker.com ---
33
Treatment of chronic angle closure
--- Content provided by FirstRanker.com ---
? Laser Peripheral Iridotomy (PI) in affected eyealong with Prophylactic PI in fellow eye
34
--- Content provided by FirstRanker.com ---
Laser Peripheral Iridotomy? Complications of laser therapy
1. Bleeding
2. IOP elevation
--- Content provided by FirstRanker.com ---
3. Iritis4. Corneal burns
5. Lens opacities
6. Glare and diplopia
--- Content provided by FirstRanker.com ---
35? Surgical treatment
Trabeculectomy (filtering surgery) is the
--- Content provided by FirstRanker.com ---
surgical procedure of choice
? Success:- 87- 100 % with multiple operations
--- Content provided by FirstRanker.com ---
? Complications:-? Flat AC, hypotony
? Bleb related infections
--- Content provided by FirstRanker.com ---
? Cyclodialysis
? PATIENTS REQUIRE REGULAR AND LIFE LONG
--- Content provided by FirstRanker.com ---
FOLLOW UP36
Absolute glaucoma
--- Content provided by FirstRanker.com ---
? Is the final/last stage of PACG? Clinical features:
? Painful blind eye
?Perilimbal reddish blue zone, due to dilated
--- Content provided by FirstRanker.com ---
anterior ciliary veins
?Cornea gradually becomes hazy, insensitive
--- Content provided by FirstRanker.com ---
with bullous keratopathy and filamentarykeratitis
?Anterior chamber is very shallow/flat
--- Content provided by FirstRanker.com ---
37
Clinical features of absolute glaucoma
--- Content provided by FirstRanker.com ---
? Iris is usually atrophic?Pupil is fixed and dilated
?Glaucomatous optic atrophy of the optic disc
?High IOP
--- Content provided by FirstRanker.com ---
38Management of absolute glaucoma
? Cycloablation/destruction of the secretory
--- Content provided by FirstRanker.com ---
ciliary epitheliumq Cyclophotocoagulation
q Cyclocryotherapy
q Cyclodiathermy
--- Content provided by FirstRanker.com ---
? Rarely? Retrobulbar alcohol injection
? Enucleation of eyeball
39
--- Content provided by FirstRanker.com ---
Complications
? Corneal ulceration
? Staphyloma formation (Ciliary/Equatorial)
--- Content provided by FirstRanker.com ---
? Atrophic bulbi (Shrunken eye)40
Conclusion
--- Content provided by FirstRanker.com ---
? Primary angle closure glaucoma is apotentially sight threatening condition,
characterized by occludable anterior chamber
--- Content provided by FirstRanker.com ---
angles.
? Obstruction of aqueous outflow results in rise
--- Content provided by FirstRanker.com ---
of intra ocular pressure, optic nerve damageand visual field defects.
? Management may include medical, laser
--- Content provided by FirstRanker.com ---
and/or surgical modalities.
41
--- Content provided by FirstRanker.com ---