Primary Angle Closure
Glaucoma
Definition
• Defining factor of angle closure is occlusion of TM by
peripheral iris
• Irido-trabecular touch
• Reduced aqeous drainage
• Leads to increase in fluid and damage to retinal
ganglion cells and glaucoma
Mechanism
• 2 mechanisms
responsible • Iris pulled forward
• Iris pushed forward from • Inflammatory membrane
behind • Fibrovascular tissue at angle
• Pupillary block • ICE syndrome
• Ant subluxated lens
• Plateau iris configuration
• CB inflammation / cyst /
tumor
• Choroidal effusion /
detachment
Pathophysiology
• Relative pupillar block
• Contact between the posterior iris and ant lens surface
• Resistance to aqeuos flow from PC to AC
• Pressure difference leads to bowing of peripheral iris forward (iris
bombe)
• If the angle is predisposed then ITC may occur leading to blockade
of drainage and high IOP
• Without Pupil block
• Angle crowding
• Presence of thick iris folds
• Plateau iris configuration
Prevalence
• European population - 0.4%
• Higher prevalence in Eskimo/inuit and Chinese
population
• Worldwide prevalence is 0.7%
Risk factors
• Patient factors
• Increase Age
• Pupil block in elderly due to thickened forward movement of lens
• Female gender
• Race
• Eskimos / Chinese, very rare in black population
• Positive family Hx
• Use of topical or systemic medication associated with angle closure
• Muscle relaxants
• Bronchodilators
• Sympathomimetics
• Topiramate - MCQ
Risk factors and examination
• Ocular risk factors • Examination
• Narrow angle • VA
• Hypermetropia • GAT
• Thickened lens • CCT
• Gonioscopy both eyes
• Physiological risk factors • Dilated exam shouldn’t be
done
• Mid dilated pupil in semi
dark light
Classification of Primary angle
closure
PACS PAC PACG
• Acute
• Subacute
• chronic
Gonio Gonio Gonio
• ITC >= 2 quadrants • ITC >= 2 quadrants • ITC >= 2 quadrants
• No PAS • PAS
IOP Normal Raised IOP Episodes of severe IOP rise
Glaucomatous optic Glaucomatous optic Glaucomatous optic
neuropathy neuropathy neuropathy
• No evidence • No evidence • Present
Management
PACS
• Zhongshan angle closure prevention trial – conversion to AAC
is 8 per 1000 eyes / year
• 1 in 4 PACS develop high IOP or PAS in 5 years
• ZAP trial suggests low risk of disease progression without laser
PI
Management
PACS
• Laser PI considered in high risk individuals with any of
the following risk factors
• High hyperopia
• Only eye
• Requirement of repeated dilation e.g diabetes
• Use of antidepressants or anticholinergic meds
• Limited healthcare access
• Family hx of significant angle closure
Management
PAC
• 1 in 3 chance of conversion to PACG within 5 years
• EAGLE study
• Age > 50 years and IOP > 30 mmhg
• Reasonable to consider primary lens extraction
• EAGLE study didn’t study younger population and
people with low risk of progression i.e IOP < 30 mmhg
• For such patients LPI is the treatment of choice
Management
PACG
• Intervention to widen the angle
• > 50 years CLE – EAGLE study
• Younger patients LPI
• Medical intervention
• Consider long term pilocarpine
• Poorly tolerated , should only be used if it successfully opens the
angles
• Antiglaucoma meds as per POAG management
Management
PACG
• Surgical management
• Trabeculectomy
• Should be avoided in very small AL due to risk of
complications such as malignant glaucoma
Acute Angle Closure
Glaucoma
Case presentation
Case
• Received a call from ED doctor
• Patient 78 years old
• Female gender
• Presenting complaints (started at 4 pm)
• BOV , haloes around light
• Nausea and vomiting with 3 x episodes
• Right side eye pressure and headache
• No temporal tenderness, no jaw claudication
• Right sided congested eye with fixed pupils
• POH – nil significant
• Family Hx – NAD for any ocular disease
• PMH – mastectomy, hysterectomy, DM -, HTN - ,
asthma -, cardiac problems
• Was initially triaged and investigated as intracranial
bleed and brain imaging was done which came out to
be normal
• Oral analgesics and antiemetics were given but of no
benefit
• At this point ED doctor was convinced that it is an eye
problem – hence he made the call
• Examination
• VA OD UA 6/60, OS UA 6/9 PH 6/7.5
• Pupils
• OD fixed dilated , OS reactive and reverse RAPD –ve
• SLE
• Conjunctival congestion more pronounced circumcorneally
• Corneal edema ++, epithelial bullae
• Van herick OD grade 0, OS grade 1/2
• Gonio
• OD hazy view grade 0, OS grade 2 – 270 deg, grade 1 – 90 deg
• GAT ??
• Examination
• VA OD UA 6/60, OS UA 6/9 PH 6/7.5
• Pupils
• OD fixed dilated , OS reactive and reverse RAPD –ve
• SLE
• Conjunctival congestion more pronounced circumcorneally
• Corneal edema ++, epithelial bullae
• Van herick OD grade 0, OS grade 1
• Gonio
• OD hazy view grade 0, OS grade 2 – 270 deg, grade 1 – 90 deg
• GAT >80 / 16
• Working diagnosis – Acute angle closure glaucoma
• Management
• 0:00 hours
• Patient in supine position
• IV line secured with 500 mg IV acetazolamide
• 500 mg oral Diamox also given
• Pilocarpine 2% instilled in BE
• G azarga, g Xalatan stat
• G iopidine every 20 mins
• G maxidex stat
• 0:45 hours
• Examination
• IOP 78, cornea still hazy with epithelial bullae
• Patient still complaining of nausea and pain
• Management
• Patient still in supine
• G azarga, G Xalatan stat
• G iopidine every 30 mins
• G maxidex stat
• Corneal massage done in an attempt for indentation
• 1:45 hours
• Examination
• IOP 50,
• Cornea cleared a bit and I thought that I will be able to do laser PI
• Management
• YAG PI done in BE with consent, good gush of fluid noticed
• Dexa BE stat
• Azarga, Xalatan stat RE (now a total of three times)
• G iopidine BE stat
• 3:00 hours
• Examination
• Patent PIs in BE, slightly small but functioning
• IOP still 48
• Cornea became hazy with SPEE’s
• Only reassuring thing was van herick grade 3 in BE and patient feeling
subjectively better
• Management
• Not sure at this point
• LPI already done
• Antiglaucoma drops were maxed out
• Diamox was maxed out
• Thinking about IV mannitol
• Advise – nothing much can be done at this moment just repeat iopidine
and g dexa and review in 90 mins
• 4:30 hours
• Examination
• IOP 16/11
• Cornea cleared up with slight haze
• Patent PI’s
• Pupil constricted in BE
• Patient discharged with next day follow up with following
meds
• Tab Diamox 250 mg QID
• G maxidex RE 2 hrly, LE QDS
• G iopidine TDS RE
• G azarga BD RE
• G pilo BD RE
• Drink plenty of water
• Patient advised to come early if symptoms reoccur before review
appointment
Learning outcomes
• Percentages are important
• Iopidine comes in 2 percentages
• 0.5 and 1% , better to use 1%
• Pilo 2% and 4%
• PF minims as it causes less SPEE
Thankyou
