Angle Closure
Glaucoma
CLASSIFICATION
Angle-Closure Glaucoma
Primary Secondary
Acute (AACG) Chronic (CACG) 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 BLOCK
1. Iris has large arc of
contact with anterior
surface of lens
2. Resistance to
aqueous flow from
posterior to anterior
chamber (relative
pupil block)
4. Iris lies against
trabecular meshwork
impede aqueous
3. Pupil dilates, humor drainage ↑
peripheral iris IOP
becomes more
flaccid and pushed
anteriorly
SYMPTOMS
1. 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
SIGNS
1. 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 Plus 3 of the following
following SYMPTOMS: SIGNS
• Ocular pain • IOP > 21mmHg
• Nausea/ vomiting • Conjunctival injection
• Hx of intermittent • Corneal epithelial
BOV with halos edema
• Mid-dilated non
reactive pupil
• Shallower chamber in
presence of occlusion
Severe Ciliary injection, Complete angle
edematous Shallow closure
cornea, Dilated, anterior
unreactive, chamber
vertically oval
pupil
DIFFERENTIAL DIAGNOSIS
Acute Acute Acute Corneal
conjunctivitis iridocyclitis congestive trauma or
glaucoma infection
Incidence Extremely Common Uncommon Common
common
Discharge Moderate to None None Watery or
copious purulent
(mucopurulent
Vision )No effect on Slightly Markedly Usually
vision blurred blurred blurred
Pain variable Moderate Severe Moderate to
severe
Conjunctival Diffuse, more Mainly Diffuse Diffuse
injection toward circumcorneal
fornices
Cornea Clear Usually clear Hazy Change in
clarity related
to cause
Pupil size Normal Small Semidilated Normal
and fixed
Pupillary light Normal Poor None Normal
response
Intraocular Normal Normal Elevated Normal
pressure
Smear Causative No organisms No organisms Organisms
organisms found only in
corneal ulcers
due to
infection
MANAGEMENT
Emergency treatment is
required – preserve the sight!
– 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-blockers
3. Topical steriods four times daily to lower the intraocular
pressure and decongest the eye
• Evaluate IOP
• Evaluate adjunct drops
• May need osmotic agents? Immediate
Reassessment iridotomy?
• Start with Pilocarpine (myotic drug)
Approx 1 hr every 15mins x 2 doses
after initial RX
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
1. 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
