PRIMARY ANGLE CLOSURE GLAUCOMA

What is glaucoma ?
 Glaucoma is a chronic, progressive optic neuropathy caused by a
group of ocular conditions, which lead to characteristic
morphological changes at the optic nerve head and in retinal fiber
layer.
 The most common risk factor known is a raised intraocular pressure.
 A sustained increase in intraocular pressure may be due to
 increased formation of the aqueous humour,
 difficulty in its exit,
 or a raised pressure in the episcleral veins
 MOST COMMONLY due to increased resistance to its drainage
through the angle of the anterior chamber and/or to the circulation of
the aqueous at the pupil
 Primary angle closure glaucoma
Not a/w any other ocular condition
Absence of signs of secondary glaucoma
or a non glaucomatous cause of optic
atrophy
anterior chamber angle is closed
(viewed on gonioscopy)
Chronic progressive optic neuropathy
• RNFL thinning
• Glaucomatous optic nerve
damage
Characterstic visual field loss
What is a closed anterior chamber angle?
Aqueous production and drainage
Classification

Primary angle closure suspects Primary angle closure

-IOP<21 -IOP>21
-OD normal -OD normal
-VF normal -VF normal

ANGLE IS
CLOSED

Primary angle closure glaucoma

-IOP>21
-OD Changes +nt
-VF changes +nt
Pupil configurations
Grading of angle width
 Shaeffer
 Spaeth
 Shie
 Van hericks
Mechanism of angle closure
 Relative pupillary block-
 Non-pupillary block
Risk factors

• Age. The average age of relative pupillary block is about 62

years at presentation. Non-pupillary block forms of primary angle closure tend to occur at a
younger age.
• Gender. Females are more commonly affected than males.
• Race. Particularly prevalent in Far Eastern and Indian Asians, where non-pupillary block is
relatively more significant.
• Family history. Genetic factors are important but poorly defined, with an increased prevalence of
angle closure in family members.
• Refraction. Eyes with ‘pure’ pupillary block are usually hyper- metropic. Non-pupillary block
mechanism can occasionally
occur in myopic eyes. Up to one in six patients with hyper- metropia of one dioptre or more are
primary angle closure suspects, so routine gonioscopy should be considered in all adult who are
hypermetropic.
• Axial length. Short eyes tend to have a shallow AC secondary
to a relatively anterior lens position. Eyes with nanophthalmos (axial length less than 20 mm) have
a very short eye and are at particular risk.
Diagnosis
 Symptoms
 Signs
Investigation
Anterior segment OCT (AS-OCT – see Fig. 11.16, ultrasound biomicroscopy) or Scheimpflug photography
may be useful to supplement gonioscopic findings and for patient education.
• Anterior chamber depth measurement is helpful in some cases.
• Biometry if lens extraction is considered.
• Posterior segment ultrasonography in atypical cases to exclude causes of secondary angle closure.
• Provocative testing. This may aid decision-making in some circumstances, particularly when plateau iris
syndrome is
suspected.
○ Pharmacological mydriasis is a poor discriminator and carries a small risk of precipitating APAC in
susceptible
patients without a patent iridotomy.
○ Dark room/prone provocative test (DRPPT): the patient sits in a dark room, face down for 1 hour without
sleeping (sleep induces miosis). The IOP is checked before and immediately after the test, as IOP can
normalize very rapidly. An IOP rise of 8 mmHg or more is considered significant. Gonioscopy without
indentation should be used to confirm closure of the angle. If the test is positive in a patient with a patent laser
iridotomy, the underlying anatomical cause is usually plateau iris, which can be confirmed with an OCT scan.
A positive response is abolished after lens extraction.
d/d of acute IOP elevation
Lens-induced angle closure due to a swollen or subluxated
lens.
• Malignant glaucoma (aqueous misdirection), especially if the patient has recently undergone
intraocular surgery.
• Other causes of secondary angle closure, with or without pupillary block.
• Neovascular glaucoma may occasionally cause the sudden onset of pain and congestion.
• Hypertensive uveitis, e.g. iridocyclitis with trabeculitis (par- ticularly herpetic including
cytomegalovirus), glaucomatocy-
clitic crisis (Posner–Schlossman syndrome).
• Scleritis with or without angle closure.
• Pigment dispersion.
• Pseudoexfoliation.
• Orbital/retro-orbital lesions including orbital inflammation, retrobulbar haemorrhage and
carotid-cavernous fistula.
Treatment
 APAC
 PACS
 PAC and PACG