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Canadian Ophthalmological Society

Evidence-based Clinical Practice Guidelines for the Management of Glaucoma in the Adult Eye

Angle-closure Glaucomas

Angle-closure glaucomas
• The most useful classification for angle-closure glaucoma is based upon etiology. • The most important criterion is the presence or absence of pupil block, with further subclassification into primary and secondary mechanisms. • The prevalence of PACG varies significantly among different ethnic groups.
Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

– narrow angle at risk of acute closure with normal IOP. • Patients may present with what appears to be chronic OAG. .44(Suppl 1):S1S93. Can J Ophthalmol 2009.Angle-closure glaucomas • Patients with PACG commonly present with 1 of 3 possible scenarios: – acute angle closure. but angle closure is subsequently discovered on gonioscopy. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. or – creeping angle closure with or without elevated IOP.

.Classification of angle closure based on functional cause Pupil Primary Examples of secondary • • • • • Posterior synechiae Silicone oil AC IOL without iridectomy Lens subluxation or lens swelling Posterior mechanisms − Choroidal tumour − Choroidal effusion o medication-induced (sulfonamides) o spontaneous Pupil block Primary acute or chronic angle closure Non-pupil block Plateau iris syndrome − Ciliary block − Lens-induced • Anterior mechanism − Angle neovascularization − Iritis − ICE syndrome − Epithelial down growth Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.44(Suppl 1):S1S93. Can J Ophthalmol 2009.

44(Suppl 1):S1S93. .Risk factors for development of primary angle closure • • • • • • • • • Axial hyperopia Family history of angle closure Advancing age Female gender East Asian ethnicity Inuit ethnicity Latino ethnicity Shallow peripheral anterior chamber Short axial length eyes Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009.

Acute angle closure: Signs and symptoms Symptoms include: • • • • • • • • • • • • • Severe pain Headache Nausea and vomiting Blurred vision Halos around lights Conjunctival injection Ciliary flush Corneal edema Fixed mid-dilated pupil Shallow anterior chamber Elevated IOP Sometimes glaukomflecken The angle is observed to be closed on gonioscopic examination Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Signs include: .44(Suppl 1):S1S93. Can J Ophthalmol 2009.

Can J Ophthalmol 2009. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.Narrow angle at risk of closure (angle-closure suspect) • A patient would be considered an angle-closure suspect if he or she had iridotrabecular contact on gonioscopy without PAS. intermittent angle closure is possible. . however. and without GON and VF damage.44(Suppl 1):S1S93. • There are usually no symptoms associated with a narrow angle.

– Trabecular meshwork. while still visible.Narrow angle at risk of closure (angle-closure suspect) (cont’d) • Signs of narrow angle at risk of closure include: – Shallow peripheral anterior chamber and an open angle on gonioscopy. • The IOP is not elevated. is almost or partially occluded. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009.44(Suppl 1):S1S93. .

44(Suppl 1):S1S93. – PAS in portions of the angle. Can J Ophthalmol 2009. and – possible glaucomatous VF defects. . – possible optic disc damage. • Signs include: – normal or elevated IOP. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.Creeping angle closure • There are no symptoms associated with creeping angle closure.

Diagnosis of Angle Closure Glaucomas .

Can J Ophthalmol 2009. and – personal history indicative of symptoms of previous intermittent attacks of angle closure. that may cause anterior movement of the lens iris diaphragm (e.44(Suppl 1):S1S93. sulfonamides) – family history of acute glaucoma or previous laser iridotomy in a first-degree relative. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. .. History must include: – whether the pupil has ever been pharmacologically dilated. – medication history to elicit the use of medications that may dilate the pupil.Diagnosis of angle closure glaucoma • • Diagnosis requires a detailed history and physical exam.g. such as those: o o o o with anticholinergic effects/side effects that counteract the iris sphincter muscle with sympathomimetic effects that work on the iris dilator muscle.

it is important to note: – visual acuity – refractive error – pupil size and reaction – presence of corneal edema – anterior chamber depth centrally and peripherally – presence of iris or angle new vessels indicative of neovascularization – presence of anterior chamber inflammation – IOP – lens appearance Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.44(Suppl 1):S1S93.Diagnosis of angle closure glaucoma • On examination. Can J Ophthalmol 2009. .

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009.44(Suppl 1):S1S93.Diagnosis of angle closure glaucoma • Gonioscopy of both eyes is mandatory to assess the depth of the anterior chamber and the presence of PAS (compression gonioscopy with a Zeiss-type lens is very useful in differentiating PAS from apposition). .

use of compression gonioscopy) is fundamental to assess the presence of angle closure in patients suspected of having narrow angles [Consensus]. performed under ideal conditions (dim ambient light. .Gonioscopy technique in narrow angles Recommendation Careful gonioscopy. Can J Ophthalmol 2009. narrow light beam from the slit lamp. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.44(Suppl 1):S1S93.

Treatment of Angle-Closure Glaucomas .

Can J Ophthalmol 2009. – chronic angle closure. or – secondary angle closure (which will further depend upon the particular underlying mechanism). Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. .Treatment of angle-closure glaucoma • Treatment should be based on the type and cause of the angle closure.44(Suppl 1):S1S93.e.: – primary acute angle closure. i. – narrow angle with normal IOP.

44(Suppl 1):S1S93. . agents to lower IOP are indicated.Treatment of primary acute angle closure • Upon diagnosis. including: – topical beta blockers – topical miotics – topical alpha-2 adrenergic agents – topical and (or) systemic carbonic anhydrase inhibitors – prostaglandins – systemic hyperosmotics Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009.

88:1091–3.44(Suppl 1):S1S93.Treatment of primary acute angle closure (cont’d) • Topical glycerol 100% (to achieve temporary clearing of the cornea when edema is present) may be useful. Anderson DR. 1. Can J Ophthalmol 2009. . Am J Ophthalmol 1979. • Corneal indentation (Anderson manoeuvre)1 with the tip of the Goldmann tonometer or Zeiss 4mirror lens may be useful. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. • Laser iridotomy should be performed when the cornea is clear.

practice guidelines for the management of glaucoma in the 5. et al.107:2092–6. Ophthalmic Surg 1992. Canadian Ophthalmological Society evidence-based clinical 3. Can J Ophthalmol 2009.44(Suppl 1):S1S93. adult eye. when the acute attack cannot be broken.3 or surgical iridectomy4 may be useful. Int Ophthalmol 1988.23:108–12. Lai JSM. . Greve EL. et al.5 1.Treatment of primary acute angle closure (cont’d) • In some instances. Schwartz GF. J Glaucoma 2002.2 lens extraction. 2. et al. peripheral laser iridoplasty may be helpful.1 • In some instances. • Laser iridotomy to the fellow eye is indicated to prevent an attack in the fellow eye (if it is similarly predisposed). et al. Ophthalmology 2002. Lam DSC. anterior chamber paracentesis.12:157–62.109:64–70.11:484–7. Ang LP. Ophthalmology 2000. 4.

et al. .44(Suppl 1):S1S93. or – when more than 180° of trabecular meshwork cannot be visualized with proper gonioscopic maneuvers. Can J Ophthalmol 2009. Ophthalmology 2000. 2.113:1087–91.Treatment of narrow angle with normal IOP • Laser iridotomy is effective as a preventive measure in patients at moderate to high risk of experiencing an angle closure attack. Friedman DS.2 • An occludable angle would include: – those with any degree of appositional closure. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.107:2092–6.1. 1. • When the trabecular meshwork can be visualized for 360°. but the approach is very narrow and therefore felt to be at risk for closure. Ang LP. et al. Ophthalmology 2006. consideration should also be given to performing an iridotomy.

Friedman DS. et al. Ophthalmology 2006. et al.44(Suppl 1):S1S93. . Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009.113:1087–91. 1.107:2092–6. Ang LP. 2.Laser iridotomy — prophylaxis against acute angle closure Recommendation Laser peripheral iridotomy should be performed in patients with narrow angles at risk for an attack of acute angle closure [Level 1B1.2]. Ophthalmology 2000.

• Once the pupil block component has been resolved by laser iridotomy.Treatment of chronic angle closure • Angle closure becomes chronic when permanent PAS develop. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.44(Suppl 1):S1S93. Can J Ophthalmol 2009. . the IOP control is achieved by the same protocol as with chronic open-angle glaucoma.

lensectomy may be indicated. intravitreal anti-VEGF medication may help cause regression of the fibrovascular membrane.Treatment of secondary angle closure • Treatment is aimed at the specific etiology. e. .44(Suppl 1):S1S93. Can J Ophthalmol 2009. – In neovascularization.g. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.: – In lens-induced mechanisms.

It is not indicated in cases secondary to anterior mechanisms such as angle neovascularization. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. iritis with PAS. It is even indicated in suspected cases of angle closure due to posterior mechanisms or plateau iris appearance in order to eliminate any possible pupillary block component. Can J Ophthalmol 2009.Laser iridotomy — suspected pupillary block Recommendation Laser peripheral iridotomy should almost always be considered to remove the pupil block component in angle closure. as pupil block is not typically a factor in these situations [Consensus].44(Suppl 1):S1S93. . iridocorneal-endothelial syndrome or epithelial down growth.

Neovascular Glaucoma .

Can J Ophthalmol 2009. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. .44(Suppl 1):S1S93. or – diabetes mellitus.Neovascular glaucoma • Neovascular glaucoma is a common form of secondary non-pupil block anterior-mechanism glaucoma. which contracts to create PAS and angle closure. • The most common inciting factors are: – posterior segment ischemia due to central retinal vein occlusion. • These lead to anterior segment iris and angle new vessel formation. • The angle new vessels form a fibrovascular membrane.

Iliev ME. Can J Ophthalmol 2009. . et al.1 1.91:1631–5. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Br J Ophthalmol 2007. and – possibly intraocular injection of anti-VEGF medication. • If there is significant visual potential. • IOP is controlled by the usual protocol as for openangle glaucoma.Treatment of neovascular glaucoma • Treatment is aimed at controlling the cause of the new vessels: – by PRP.44(Suppl 1):S1S93. cycloablation is useful. filtering surgery is often required. • If there is minimal visual potential.

Ciliary Block Glaucoma .

Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.44(Suppl 1):S1S93. • It may occur in phakic. pseudophakic or aphakic eyes. • It is likely due to ciliary body rotation and aqueous misdirection posteriorly. Can J Ophthalmol 2009.Ciliary block glaucoma • Ciliary block glaucoma (malignant glaucoma or aqueous misdirection) is a rare cause of secondary non-pupil block posterior-mechanism glaucoma. and may even occur after a laser iridotomy. . • It may occur after intraocular surgery of any kind.

Can J Ophthalmol 2009.66:2495–502. Chandler PA. .1 • Acute treatment includes: – topical beta blockers – topical and (or) systemic carbonic anhydrase inhibitors – prostaglandins.44(Suppl 1):S1S93. alpha-2 adrenergic agents – systemic hyperosmotics 1. et al. as well as – maximal cycloplegia with atropine.Treatment of ciliary block glaucoma • Initial treatment includes: – laser iridotomy to minimize any potential pupil block component. Am J Ophthalmol 1968. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

98:137–43. . Can J Ophthalmol 2009. Epstein DL.44(Suppl 1):S1S93. 1. Am J Ophthalmol 1984. et al.Treatment of ciliary block glaucoma (cont’d) • If the attack cannot be broken: – in phakic eyes: • a vitrectomy is indicated – in pseudophakic or aphakic eyes: • an attempt at Nd:YAG laser lysis of the anterior hyaloid and posterior capsule (hyaloidotomy or vitreolysis) may avoid a vitrectomy1 Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.

.44(Suppl 1):S1S93. Can J Ophthalmol 2009. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye.Aqueous misdirection syndrome Recommendation Ciliary block (aqueous misdirection syndrome) must be considered in any patient with postoperative shallow anterior chamber with elevated or normal IOP [Consensus].