Angle Closure Glaucoma

Question 1

Risk factors for angle closure glaucoma

Answer 1

Chinese Asians more common, Eskimo’s higher prevalence compared to caucasians

• women 70%; shallow chamber, smaller axial length
• older people
• hyperopia
• smaller axial length
• fellow eyes of an individual at risk
• first degree relatives of an angle closure patient

Question 2

Precipitating factors for angle closure glaucoma

Answer 2

Factors that produce dialtion (dim illumination, emotional stress, drugs)
Factors that produce miosis (Rare)

Question 3

Primary angle closure

Answer 3

180 degrees or less of TM visible, IOP normal, disc normal

Question 4

Secondary angle glaucoma

Answer 4

Secondary to systemic problem

Question 5

Pupillary block and angle closure

Answer 5

• most common form of primary angle closure
• initiating event-increased resistance of the flow of aqueous humor at pupil and anterior surface of lens
• forward bending of iris
• closure of angle

Question 6

Symptoms of angle closure glaucoma (acute)

Answer 6

Acura pain
Nausea and vomiting 
Blurred vision
Colored halos around lights 
Loss of vision

Question 7

Signs of acute angle closure glaucoma

Answer 7

• conjunctival and ciliary congestion
• corneal edema
• shallow peripheral anteiror chamber with cells and flare
• intraocualr pressure usually exceeds 40mmHg

Question 8

Signs of prior attack of angle closure

Answer 8

Iris atrophy
Posterior synechiae
Glaukomflecken
Structural optic nerve damage-cupping or pale nerve

Question 9

Glaucomfleckin

Answer 9

Specific cataract to acute angle closure attack

Question 10

More signs of acute closure glaucoma

Answer 10

• severe corneal edema
• dilated, unreactive, vertically oval pupil
• ciliary injection
• shallow anterior chamber
• complete angle slower (Shaffer grade 0)

Question 11

Why do we use minimal light in gonio when checking the angle for angle closure glaucoma

Answer 11

Make sure you do not use bright light, because it will cause the pupil to constrict some and make the angle appear to more open than it actually is

Question 12

Iris synechiae

Answer 12

• iris is in contact to the peripheral cornea and the TM
• during the first few hours of an acute attack snechiae
• longer the iris is against the angle, the risk of anterior synechiae formation is higher and almost certain
• once this happens, the angle will not longer open with an I ride Tony and TM outflow will be permanently affected

Question 13

Causes of halos in angle closure glaucoma

Answer 13

Epithelium edema of the cornea

Question 14

Stenopic slit and halos

Answer 14

◦ Slit in the trial lens
◦ Halos 360 in glaucoma
◦ Halos only in certain spots in cataracts

Question 15

Corneal edema and halos

Answer 15

• IOP is very higher, 50mmHg or higher
• aqueous that is forced into the corneal stroma causing stretching of collagen lamellae and, eventually, epithelial edema

Question 16

Mid dilated unreactive pupil in glaucoma

Answer 16

• paralysis and ischemia of the pupillary sphincter, caused by the increase in IOP
• causing a fixed mid dilated pupil

Question 17

Cilinary and conjunctival vessels congestion

Answer 17

• venous congestion: this occurs when the IOP exceeds that of episcerla veins
• iris blood vessels become dilated and also the veins in the conjunctiva, given the patient a painful red eye

Question 18

Iris atrophy

Answer 18

-the abrupt increase in IOP causes an interruption of the arterial supply to the iris, resulting in ischemia which causes damage to the iris, leaving behind patches of stromal atrophy

Question 19

Aqueous flare and acute angle closure

Answer 19

Mild flare due to break down of BAB so there is protein in AC

Question 20

Signs of postcongestive angle closure

Answer 20

• folds in descemets
• stromal iris atrophy with spiral like configuration
• psoteiuror synechia
• fine pigment on iris
• fixed dilated pupil
• glauckomfleckin

Question 21

Autonomic stimulation and angle closure

Answer 21

• nausea and vomiting may accompany the acute angle closure attack
• the oculocardiac reflex produces bradycardia (slow heart rate) and there is often profuse sweating

Question 22

Sub acute angle closure

Answer 22

-symptoms in subacute ACG may be similar to those in acute angle closure glaucoma, but of intermittent or lower intensity, and my spontaneously disappear

Question 23

Chronic angle closure glaucoma

Answer 23

• peripheral anteiror synechiae (PAS)
• increased IOP
• pateitn asymptomatic until vision loss

Question 24

Signs of chronic angle closure glaucoma

Answer 24

• similar to POAG with cupping and field loss
• easily missed unless routine gonioscopy performed
• variable amount of angle closure

Question 25

Combined mechanism glaucoma

Answer 25

- open angle and angle closure mechanisms at work | - diagnosis-IOP elevated post angel closure and successful iridotomy and open angle

Question 26

Pupillary block

Answer 26

- eyes with shallow AC - more anterior position of the lens - greater anterior surface curvature of lens, increases the area of contact of the posterior iris surface to the lens - this causes a facilitating a pressure differential between the AC and PC that causes forward bowing of the relaxed, peripheral iris

Question 27

Antomical mechanism of angle closure

Answer 27

Lens size and position Eyes with a thicker and anteriorly positioned lens tend to have shallower AC Aging increases lens thickness

Question 28

Mechanism of plateau iris and angle closure

Answer 28

- the AC depth appears to be normal - the iris plane remains flat - but the angle looks narrow or closed due to the shape of the peripheral iris - iris drops abruptly in the far periphery, making a narrow recess over the TM - th meachnisms that increase iridotrabecular contact are thicker iris, anteiror iris insertion, anterior position of the CB

Question 29

The mechanisms that increase iridotrabecular contact are

Answer 29

Thicker iris Anteiror iris insertion Anterior position of the CB

Question 30

Plauteau iris caution

Answer 30

- eyes with plateau iris configuration may have angle closure when the pupil is dilated - iridotrabecular apposition

Question 31

Plateau iris with relative pupillary block treatment

Answer 31

-treatment is with peripheral iridotomy

Question 32

Plateau iris syndrome

Answer 32

- whenever gonio confirms angle closure in the presence of a patent iridotomy - when performing indentation in these cases the iris can be pushed posteriorly, so it assumes a concave shape that follows the lens curvature, but the peripheral iris remains elevated due to the position of the ciliary processes - treatment for these cases should be argon or diode laser iridoplasty

Question 33

Medical treatment for angle closure

Answer 33

- pilocarpine - hyperosmotic agents - CAI - A agonists - Prostaglandin analogs - BBlockers

Question 34

Laser treatments for angle closure

Answer 34

- argona laser peripheral iridotomy - argon laser iridoplasty - argon laser iridotomy - Nd:YAG iridotomy

Question 35

Surgical treatment for angle closure

Answer 35

- AC paracentesis - Iridectomy - lens/cataract extraction - filtering surgeries - cyclodestructive surgeries

Question 36

Goals of medical treatment for angle closure

Answer 36

- lower IOP - alleviate pain - clear cornea - prevent synechiae

Question 37

IV meds and ACG

Answer 37

- acetaxolamide 500mg IV - IV mannitol - best therapy is hot always available in clinic

Question 38

Treatment protocol-ACG-ABC procedure

Answer 38

- A2 agonist-brimonidine - BBlocker-timolol (caution in asthamatics) or betaxolol - CAI-dorzolamide (caution sulpha allergy contraindications) Each med given every 15 minutes

Question 39

Oral meds and ACG

Answer 39

- oral CAI - two tablets of 250mg acetozolamide (caution sulpha allergies contraindication) Works good when patient can retain medication-vomitting common with ACG

Question 40

How to bring IOP down in office

Answer 40

Give the meds suggested - check IOP after 1 hour if lower - add pilocarpine every 15 minutes for 45 minutes and repeat the procedure - seek OMD opinion-refer patient

Question 41

Take home meds to ACG

Answer 41

- prednisone acetate 1% q1-6 hours (approximately every 3 hours) - acetaxolamide 500mg sequel BID - AAgonist or BBlocker BID - pilocarpine 2% QID

Question 42

Indications of iridotomy

Answer 42

- occludalbe angle - contralateral eye of an acute ACG - narrow or closed angle in mroe than 180 degrees with optic nerve damage with high IOP - acute ACG

Question 43

Indications of peripheral iridoplasty

Answer 43

- plateau iris - in preparation for laser trabeculoplasty - after iridotomy if iris apposition is still present - before an iridotomy, in cases of thick, inflamed or rubeosis irises

Question 44

Why is IV medication the best for ACG

Answer 44

Acetaxolamide Mannitol Bypasses first pass metabolism This will also prevent nausea and vomiting