ANGLE

CLOSURE
GLAUCOMA
EYE DEPARTMENT
PMC-AJK
 Angle closure – Iridotrabecular apposition /adhesion
obstruction to aqueous outflow
Raised Intraocular pressure.

 Anatomical features : shallow AC

Thicker lens
Increased anterior lens curve
Shorter Axial length
Smaller corneal diameter
Increased ratio of lens thickness to
axial length

Occludable Angle:
When Pigmented trabecular meshwork is not visible
without indentation or manipulation in at least 3 or 4
quadrants
Stages
1. Primary angle-closure glaucoma suspect (latent)

2. Subacute or intermittent primary angle-closure

glaucoma

3. Acute primary angle-closure glaucoma

4. Chronic primary angle-closure glaucoma

5. Absolute primary angle-closure glaucoma

Risk Factors

 Positive family history for angle closure

 Age over 40-50 yrs
 Women
 History of Angle closure symptoms
 Hyperopia
 Pseudoexfoliation
 Racial group Asians [far eastern]
 Relative Pupillary block    •   

Failure of aqueous flow through the mid dilated pupil leads to a

pressure differential between the anterior and posterior
chambers,
with resultant anterior bowing of the lax iris [Iris bombe]
blocks trabecular meshwork and iridolenticular contact
 Non-pupillary block relating to the iris    •   

 plateau iris
 anteriorly positioned ciliary processes,
 and a thicker or more anteriorly-positioned iris.
   •    
Gonioscopic examination
 Shaffer grading:

Grade 4
(35–45°) is the widest angle,[ in which the ciliary body can be visualized with ease]
    Grade 3
(25–35°) is an open angle [ in which at least the scleral spur can be identified]
Grade 2
(20°) is a moderately narrow angle [in which only the trabeculum can be identified
Grade 1
(10°) is a very narrow angle [ only Schwalbe line, and trabeculum, can be identified.

  Grade 0
(0°) is a closed angle due to iridocorneal contact and is recognized by the inability to identify the
apex of the corneal wedge.
Anatomy of angle
Slit lamp grading or PACD

 Van Herrick method:

Grade 0 – Iridocorneal contact ,

Grade 1- PACD < ¼ CT
Grade 2- PACD ¼-1/2
Grade 3- PACD more than 1/2
Sequence of events:
 Acute angle closure:
sudden ,circumferential ,iridotrabecular apposition-rapid severe rise in IOP
 Intermittent angle closure :
Self limiting episodes of ITC ,milder signs & symptoms of former
 Creeping angle closure:
slowly progressive ITC –Elevated IOP
 Chronic angle closure :
irreversible ,iridotrabecular adhesion ,asymptomatic unless significant raised
IOP.
Latent

 Symptoms are absent.

 Gonioscopy shows an ‘occludable’ angle (less than 20

degrees). The pigmented trabecular
meshwork is not visible (Shaffer grade 1 or 0) without
indentation or manipulation in at least three quadrants.
intermittant

 Attacks of raised intraocular pressure with unilateral blurring of

vision, coloured halos, mild headache and browache.
 In between the recurrent attacks the eyes are free from symptoms
 reading in dim illumination or watching television in a dark
room precipitates a pupillary blockdue to mydriasis.
 This causes a sharp rise in intraocular pressure for a short period
of time followed by a spontaneous resolution of the pupillary
block possibly due to:
i. Rest
ii. Sleep (As the pupil becomes constricted)
Acute
Decreased vision
Halos around lights
frontal headache
Ocular pain
nausea and vomiting

Elevated IOP risen rapidly

Conjunctival congestion
Corneal epithelial /stromal edema
Shallow or flat peripheral AC
mid dilated [vertical oval] pupil
absent /sluggish pupil reaction
  Fellow eye generally shows an occludable angle
Resolved acute (post-congestive) angle
closure

    
   Folds in Descemet membrane (if IOP has been reduced
rapidly), optic nerve head congestion and choroidal folds.
 Later
 iris atrophy
 irregular pupil,
 posterior synechiae and
 glaukomflecken
chronic

 In this stage the angle of the anterior chamber becomes

slowly and progressively closed Pathogenesis
Type 1(Creeping)—It is caused by gradual and progressive
closure of the angle by synechiae over atleast 180 degrees.
It always starts superiorly and progresses circumferentially.
Type 2 (Subacute)—It is caused by synechial angle closure
as a result of subacute (intermittent)
attacks secondary to the pupillary block.
End stage (absolute)

Painful blind eye with no perception of light (no PL) is the most
prominent symptom.

1. Ciliary congestion is present around the limbus.

2. Cornea is clear and insensitive with
Vesicles (bullous keratopathy) may be seen

 3. Anterior chamber is very shallow.

 4. The iris is atrophic (white patches) and may have a broad zone of
pigment around the pupil
(ectropion of the uveal pigment) due to fibrosis of the iris tissue.

5. The pupil is grey instead of jet black, dilated and vertically oval.
6. The tension is usually very high and the eyeball is as hard as stone.
7. There is deep cupping of the optic disc.
Provocative tests

 Pharmacological test:
pupillary block mechanism in mid dilated state ,increased
tension of iris .
-Performed with short acting mydriatic [phenylephrine eye
drops]
-if test proves positive –acute attack may be triggered
 Paraphysiological test :
Dark room prone test – pupil dilates in dark,lens moves
forwards in prone.
- Patient sits for 30 minutes in dark with head prone ,no
sleeping
- IOP checked rapidly ,positive if increases by 8 mm Hg
 Initial management of PACG
ATTACKPilocarpine 2%
Immediately on attack

B-blocker
Apraclonidine
Topical corticosteroid
IV osmotic agent /acetazolamide
Corneal indentation using 4 mirror lens Attack broken
Leave patient supine to allow lens move
back in position Pupil constricted
IOP lowered
Corneal clearing
If patient in pain
Topical ketorolac ,
systemic pain medication
Topical
If patient is vomiting 60 minutes pilocarpine
2%
Intramuscular metoclopramide
Topical
corticosteroids
If patient comfortable Laser
laser prophylactic iridectomy in fellow eye prophylactic
 Attack not
broken

IV Osmotic if not already

given

Clear Cornea Cloudy

cornea

Laser iridectomy Laser iridoplasty

,iridoplasty

Attack not
broken

Surger
y
Peripheral laser iridotomy :

 A procedure ,where hole is made in iris periphery allowing

aqueous to drain from PC into TM
Helps eliminate high aqueous pressure behind iris and iris
falls back.
Done using Nd:YAG laser ,150-200 microns size 3-6 mj of
power based on thickness
Topical pilocarpine 30 mins before laser therapy, identify
crypt in iris and create opening .
Post op steroids and antiglaucoma meds
Examine patency and size of iridotomy with gonioscopy
Surgical peripheral iridectomy

 Removal of iris tissue by knife or scissors

 2-3 mm peripheral corneal incision in
superotemporal site.
 Alternatively ,conjunctival peritomy and
scleral limbus incision ,nylon sutures
wound closure
 Externalised iris piece held with toothed
forceps , incised with fine scissors.
Argon laser iridoplasty

 Aim to shrink and flatten iris tissue without damage

 Placement of circumferential ring of non penetrating
contraction burns at far iris periphery – widen angle,contract
stroma
 Evenly spaced applications [4-10 burns /quadrant , 200-500
microns large
0.2-0.5 sec , low powered [200-400 mW] ,central button of
goniolens.
 Energy is defocussed so can be given in cloudy cornea also
Goniosynechialysis

 It involves stripping of peripheral anterior synechiae using

an Irrigation cyclodialysis spatula / flat iris spatula.
 Viscoelastics used to deepen the anterior chamber .
Lens extraction

Removal of lens with or without opacity due to lens size /

malposition.
Best outcomes with small incision phaco.
Trabeculectomy

 Trabeculectomy lowers IOP - creating a fistula, to allow

aqueous outflow from the anterior chamber to the sub-
Tenon space. The fistula is protected or ‘guarded’ by a
superficial scleral flap
 When medical therapy has failed to achieve adequate
control of IOP.