Cute Angle Closure Glaucoma

Question 1

What is Acute angle closure glaucoma (AACG)?

Answer 1

AACG is a type of glaucoma characterised by the blockage or narrowing of the angle formed by the cornea and the iris.

Question 2

What is the incidence of AACG in the UK?

Answer 2

Approximately 2 cases per 100,000 people per year.

Question 3

What are the risk factors for AACG?

Answer 3

• Older age
• Female sex
• East Asian ethnicity
• Medications e.g. oxybutynin, amitriptyline, tropicamide
• Hypermetropia (farsightedness)
• Family history of AACG
• Pupillary dilation

Question 4

What is the role of aqueous humour in eye health?

Answer 4

Aqueous humour is produced by the ciliary body and flows through the pupil into the anterior chamber, then drains via the trabecular meshwork into the canal of Schlemm.

Question 5

What is angle closure glaucoma?

Answer 5

Angle closure glaucoma refers to narrowing or closure of the angle due to the lens pressing against the iris.

Question 6

What are the types of angle closure glaucoma?

Answer 6

• Acute
• Subacute
• Chronic

Question 7

What is the typical cause of primary angle closure glaucoma?

Answer 7

Most cases are primary with no other pathology causing angle closure.

Question 8

What can cause secondary angle closure glaucoma?

Answer 8

• Neovascularisation of the iris
• Space occupying lesion in the eye

Question 9

What are common symptoms of AACG?

Answer 9

• Rapid onset of severe eye pain
• Blurred vision which may progress to visual loss
• Nausea and vomiting
• Headache
• Coloured haloes around lights

Question 10

What are the examination signs of AACG?

Answer 10

• Conjunctival injection in the affected eye
• Haziness of the cornea
• Mid-dilated or fixed pupil that is not reactive
• Globe feels hard and is tender on palpation

Question 11

How does open-angle glaucoma differ from AACG?

Answer 11

Open-angle glaucoma occurs with reduced drainage of aqueous humour without closure of the angle, and has an insidious onset with gradual loss of peripheral vision.

Question 12

What distinguishes acute anterior uveitis from AACG?

Answer 12

Acute anterior uveitis features an irregular pupil due to posterior synechiae and a hypopyon.

There will also be ciliary flush.

Glaucoma will have severe ani with haloes and a large semi-dilated pupil.

Question 13

What can anterior scleritis cause?

Answer 13

Painful red eye with headaches and tenderness of the pupil.

Question 14

What investigations are used for AACG?

Answer 14

• Slit lamp examination
• Gonioscopy
• Tonometry

Question 15

What is the normal range for intraocular pressure (IOP)?

Answer 15

11-21 mmHg.

Question 16

What is the typical IOP in AACG?

Answer 16

> 30 mmHg.

Question 17

What is the gold standard for measuring IOP?

Answer 17

Goldmann applanation tonometry.

Question 18

What is a crucial part of conservative management for AACG?

Answer 18

Lie the patient flat with their face up without pillows.

Question 19

What are the components of medical management for AACG?

Answer 19

• Dorzolamide (carbonic anhydrase inhibitor)
• Timolol (beta-blocker)
• Apraclonidine (alpha-2 agonist)
• Pilocarpine (cholinergic agonist)
• IV acetazolamide

Question 20

What is the definitive surgical management for AACG?

Answer 20

Peripheral iridotomy.

Question 21

Why should both eyes be treated in AACG?

Answer 21

To prevent AACG in the contralateral eye due to a risk of 40-80% in the following 5-10 years.

Question 22

What are second line options if laser peripheral iridotomy is not possible?

Answer 22

• Laser peripheral iridoplasty
• Diode laser cycloablation

Question 23

What is the treatment for acute glaucoma?

Answer 23

IV acetazolamide and topical timolol

Question 24

What is the clinical presentation of acute angle glaucoma?

Answer 24

sudden poor vision (typically less than 6/60), seeing halos, vomiting, mid-dilated pupil, and hazy cornea and it is classically triggered in dark lighting

Question 25

What are the risk factors for glaucoma?

Answer 25

Risk factors include being female, Asian and the use of certain medications including those with antimuscarinic properties, such as amitriptyline

Question 26

What is a key features of glaucoma?

Answer 26

sudden headache, nausea and loss of vision. Symptoms may worsen at night

Question 27

What is the intial anagement of glaucoma

Answer 27

IV Acetazolamide and a topical beta-blocker such as Timolol. An urgent Ophthalmology referral should be made

Question 28

What is the definitive treatment of glaucoma?

Answer 28

Peripheral iridotomy

Question 29

What is the order of drugs for use in open angle glaucoma?

Answer 29

1) Prostaglandin analogues like dorzolamide 2) Topical carbonic anhydrase 3) Alpha-2 adrenergic agonists

Question 30

What are the alpha adrenergic agonists?

Answer 30

Briminodine Apraclonidine

Question 31

What alpha adrenergic agonist is used in glaucoma?

Answer 31

Brimonidine reducing aqueous humour production and increasing uveoscleral outflow

Question 32

What are the adverse effects of alpha adrenergic agonists?

Answer 32

ocular allergy and mild systemic hypotension

Question 33

What is first line drug for glaucoma open alngle?

Answer 33

Prostaglandin analogoue

Question 34

What is the reccomended screening for patients with positive family history of glaucoma?

Answer 34

Yearly from age 40

Question 35

What is the definitive treatment for open-angle glaucoma?

Answer 35

Trabeculectomy

Question 36

What is the definitive treatment for acute loosed glaucoma?

Answer 36

Laser peripheral iridotomy

Question 37

What eye abnormality is open angle glaucoma asoicated with?

Answer 37

Myopia (nearsightedness)

Question 38

What is the aim of glaucoma treatment?

Answer 38

Reducing aqueous secretion + inducing pupillary constriction

Question 39

What is the action of beta blockers in glaucoma?

Answer 39

Reduce aqueous production

Question 40

What is the action of latonoprost?

Answer 40

Increases uveoscleral outflow

Question 41

What reduces the rate of aqueous humour production and thus decreases intraocular pressure?

Answer 41

Carbonic anhydrase inhibtior

Question 42

What drug class reduces aqueous humour production?

Answer 42

Beta blockers

Question 43

what drug reduces aqueous production?

Answer 43

Beta blocker Carbonic anydrase

Question 44

Which investigations shold be done for glaucoma?

Answer 44

Gonissocpy: using a special lens on the slit lamp which allows visualisation of the anterior chamber angle. This can highlight any blockages that may have resulted in this increasing rise in pressure Toniometry§§§§

Question 45

What is associated with hypermetropia?

Answer 45

Close angle glaucoma

Question 46

What drugs should be given for closed angle glaucoma?

Answer 46

IV Acetazolamide and timolol Pilocarpine Apraclonidine eyedrops

Question 47

How does close angle glaucoma present?

Answer 47

fixed dilated pupil with conjunctival injection and hazy cornea

Question 48

What medications should be given for open angle glaucoma?

Answer 48

Latanoprost, brimonidine, and dorzolamide eyedrops

Question 49

What is the effect of cyclopentolate in glaucoma?

Answer 49

Muscarinic receptor antagonist causing glaucoma

Question 50

How is the cornea affected in glaucoma?

Answer 50

Corneal oedema so it appears hazy