Glaucoma: Angle Closure Glaucoma

Question 1

1. Primary Angle Closure Glaucoma
   a. % of all Diagnosed Cases of Glaucoma?
   b. Why is the IOP Elevated?
2. Acute Attack of ACG can lead to Blindness when?
   a. NFL damage w/in how many hours?
3. POAG: Aq. has access to what?
   a. But Drainage is impaired due to what?
   b. Loss of Ganglion Cells/Vision is what?

Answer 1

1. a. 10%
   b. Cuz PERIPHERAL IRIS PREVENTS Aqueous from reaching the TM! (Meshwork is presumed to function normally)
2. w/in Hours or Days
   a. W/in 48 hrs
3. to the TM
   a. due to other Mechanisms
   b. Chronic, Slow and Gradual Loss of Ganglion Cells/Vision

Question 2

Epidemiology/Risk Factors

1. Race: More common in what patient populations?
2. Family History?
3. Gender?
4. Age?
5. What else?

Answer 2

1. Mongoloid Populations (Eskimos, Eastern Asians…Asians)
2. Positive is a RISK FACTOR
3. WOMEN
4. Increases (lens thickness, increasing Anterior Lens Curvature, Slight anterior displacement of the lens, pupillary miosis)
5. REFRACTIVE ERROR: More Frequently in HYPEROPIC EYES (generally smaller gloved: Gonio should be done on Patients w/Refractive Error of more than +2.50)

Question 3

Classification of Angle Closure Glaucomas

1. ACG w/PUPIL Block
   a. What is Restricted?
   b. Block can lead to what?

2 ACG w/o PUPIL BLOCK

a. PLATEAU IRIS: What is it?
b. Secondary Forms are what?

Answer 3

1. a. Normal flow of Aq. from the Post Chamber to the AC is restricted
   b. to increased pressure in the Post. Chamber which pushes the Peripheral Iris Forward (IRIS BOMBE) until it blocks the TM
2. a. a configuration of the IRIS: Central ANTERIOR CHAMBER DEPTH is NORMAL, IRIS PLANE is FLAT, and ANTERIOR CHAMBER Angle is Extremely Narrow
   b. Defines as mechanisms which cause either a pulling or pushing of the iris against the TM!!

Question 4

Angle Closure Glaucoma w/Pupillary Block

1. Primary: (4)
2. Secondary (5)

Answer 4

1. a. Acute, Chronic, Subacute, and Suspect

2. Ectopia Lentis; Nanophthalmos; Phacomorphic; Posterior Synechiae to the lens or vitreous or IOL, and Spherophakia

Question 5

Angle Closure Glaucoma w/o Pupillary Block

1. Primary (Plateau Iris) (2)
2. Secondary (Anterior “pulling” mechanism) (4)

Answer 5

1. a. Plateau Iris Configuration
   b. Plateau Iris Syndrome
2. a. Epithelial Downgrowth
   b. ICE Syndrome
   c. Inflammatory Induced (PAS)
   d. Neovascular Glaucoma

Question 6

Angle Closure Glaucoma w/o Pupillary Block (2)

1. Secondary (Posterior “PUSHING” Mechanism) (Malignant Glaucomas & Related Causes) (8)

Answer 6

1. Choroidal Detachment
2. CB Detachment
3. Intraocular Tumors
4. Lens Induced
5. Post Scleral-buckle for RD procedure
6. Post Intravitreal Air Injection
7. Post Pan-Retinal Photocoagulation Procedure for Diabetic Retinopathy
8. Retinopathy of Prematurity

Question 7

Angle Closure Glaucoma

1. Role of the CHOROID
   a. Why does it likely contribute to developing ACG?
   b. 20% Expansion =?
2. What causes Choroidal Expansion?

Answer 7

1. Due to Choroidal Expansion (increased VOLUME)
   b. takes up to 96 ul (normal AC = 100ul)
2. Changes in Choroidal Vessel Permeability

Question 8

Angle Closure Glaucoma

1. Factors Affecting ACG (Many)

Answer 8

1. Carotid Cavernous Sinus Fistula
2. Choroidal Detachment
3. Choroidal Tumors
4. Drug Induced Choroidal Effusions (Sulfa Based)
5. Extensive PRP
6. Hypotony
7. Scleritis
8. Suprachoroidal Hemorrhage
9. Acute Central Retinal Vein Occlusion

Question 9

Medications Causing ACG

1. Only one HIGHLIGHTED?

Answer 9

1. TOPAMAX (topiramte)

Question 10

Primary ACG w/Pupillary Block: Mechanisms

1. You get Apposition of what?
2. Absent EGRESS of what?
3. What does this Cause?
4. This LEADS to what occurring?
5. And finally: what happens?
   a. Can create formation of what?
6. IOP?
   a. What could happen due to increased IOP?
   b. What happens w/in 24 hrs?

Answer 10

1. Irido-Lenticular Apposition
2. Absent Egress of Aq. into the AC
3. Pressure increase in the Posterior Chamber
4. Leads to IRIS BOMBE (forward bowing of Iris due to Posterior pressure)
5. Angle Closure
   a. PAS formation if contact remains too long
6. Rises to >40mmHg!
   a. Maybe a CRAO or CRVO due to elevated IOP
   b. RNFL Damage as tissue can’t adapt to sudden pressure increase

Question 11

ACG: Differential Diagnosis

1. 7

Answer 11

1. Angle Mass
2. Early Neo Glaucoma
3. Glaucomatocyclitic Crisis
4. ICE
5. Malignant Glaucoma
6. Plateau Iris Syndrome
7. POAG w/unusually High IOP

Question 12

Glaucomatocyclitic Crisis

1. AKA?
   a. What is it?
   b. It’s Associated with what?
   c. Gonioscopy shows Open/Closed Angle
2. Tx?
3. Bottom Line: These Patients look like what?

Answer 12

1. Posner-Schlossman Syndrome
   a. Recurrent episodes: Mild, Idiopathic, UNILATERAL, Non-Granulomatous Anterior UVEITIS

b. MARKED ELEVATION in IOP (usually in 20-50 y/o)

2. STEROIDS for UVEITIS (usually reduces the IOP)
   a. If IOP stays elevated, then do a short course of Anti-Glaucoma Meds
3. They look like ACG patients. Do a thorough Gonio and SLE

Question 13

Common Signs, Symptoms and Complications

1. Acute Primary ACG
   a. Classic Signs?
   b. It is almost ALWAYS UNI/BI?
   c. Development of Pain and Symptoms is RAPID/SLOW?
   d. Pain is related to what?

Answer 13

1. EMERGENCY!!
   a. Redness, Pain (mild to severe), BLURRED VISION, Haloes, Tearing, Photophobia, Nausea and vomiting, Headache, IOP (HIGH 40-90 mmHg), Mid Dilated Pupil!
   b. UNILATERAL!
   c. RAPID!
   d. rapid rise in Pressure more than the actual IOP itself

Question 14

Common Signs, Symptoms and Complications

1. Subacute Primary ACG
   a. What kind of Angle Closure occurs?
   b. How does it resolve?
   c. Symptoms? (based on what 2 things)

d. Subacute Attacks tend to Increase/Decrease over time and may progress to one of 2 things?
2. What should we do with these patients?
3. When is the Patient at MOST RISK? (what sign do we look FOR?!)

Answer 14

1. a. INCOMPLETE Angle Closure
   b. Spontaneously
   c. Vary widely: Depends on IOP and Pt’s Pain Threshold

d. Chronic Primary ACG or have an ACUTE Angle Closure Attack
2. Monitor for Signs of Previous Angle Closure
3. Mid-Dilated Pupil

Question 15

Signs of Prior Angle Closure Attacks

1. Synechiae: What 2 types?
2. Glaukomflecken: What is it?
3. What about the Iris?
4. Pigment ANTERIOR to what Line?
5. Glaucomatous Findings (what 2?)

Answer 15

1. PAS and Posterior
2. Anterior Subcapsular Lens
3. Iris ATROPHY
4. to Schwalbe’s Line
5. Optic Nerve and Visual Field Changes

Question 16

Common Signs, Symptoms and Complications

1. Chronic Primary ACG
   a. Permanent Closure of PARTS of the ANTERIOR CHAMBER ANGLE by what?
   b. Closure of the Entire Angle may progress VERY SLOWLY and the patient may not experience symptoms until when?

Answer 16

1. a. by PAS

b. until LATE in the DISEASE!

Question 17

Primary ACG: Symptoms Summary

1. Acute: (2)
2. Sub-Acute (2)
3. Chronic: (2)

Answer 17

1. a. SYMPTOMATIC
   b. Measurable INCREASE in IOP
2. a. No Symptoms to Mild Symptoms
   b. IOP probably normal in office.
3. a. Typically Asymptomatic
   b. IOP usually Elevated

Question 18

Primary ACG Exam Components

1. Pupils: If IOP is >40 mmHg, the Iris Sphincter will be what?
2. What 5 things should be done?

Answer 18

1. FIXED
2. a. SLE
   b. Applanation IOP

c. Van Herick Angle Estimation
d. AC Depth Evaluation
e. Gonio: Indentation

Question 19

Van Herick Angle Assessment

1. Interpretation
   a. Grade 1

b. Grade 2
c. Grade 3
d. Grade 4

Answer 19

1. Angle 1/2. WIDE Open Angle. Little to NO RISK

Question 20

Angle Closure and Dilation

1. Prevalence? (understimation?…most likely)
2. Considered what kind of testing?
3. Patients are typically not aware that what is occuring?
4. Most likely time of ANGLE CLOSURE after being DROPPED?

Answer 20

1. 1:20,000
2. Provocative Testing
3. That the Angle closure is occurring
4. 90 minutes after Dilation Drop Instillation

Question 21

Provocative Testing

1. DARK ROOM TEST:
   a. Pt is placed where?
   b. MAKE SURE THE PATIENT DOESNT DO WHAT during the TEST?
   c. After this time, what is re-evaluated?
   d. A Rise that EQUALS or EXCEEDS what is considered a POSITIVE FINDING?
   e. What is repeated at this point?

Answer 21

1. a. In Dark room for 60-90 minutes after measurement baseline IOP and Gonioscopy
   b. DOESNT SLEEP (cuz parasympathetic system predominates…causing pupillary miosis…makes the test INVALID)
   c. IOP; careful not to expose patient to bright light that could cause pupillary constriction
   d. in IOP of 8 mmHg
   e. Gonio

Question 22

Provocative Testing

1. Prone Test
   a. Get baseline reading of what?
   b. Put patient how?
2. Prone Dark Room Test
   a. What is done?
   b. What is considered a POSITIVE FINDING?
3. Mydriatic Test
   a. Get baseline reading of what?
   b. Dilate Pupils with what?
   c. Re-evaluate IOP when?
   d. Rise in IOP that EQUALS or EXCEEDS what is a Positive finding?

*None of these provocative tests have demonstrated Sensitivity or Specificity in clinical TRIALS and are not considered part of STANDARD CARE!

Answer 22

1. a. IOP
   b. in Prone Position for 60-90 minutes, and make sure they stay AWAKE and avoid direct pressure on the globe
2. a. Put pt in prone position in a dark room for 60-90 minutes w/same instructions as prone test
   b. Rise in IOP that equals or exceeds 8mmHg is a positive finding for either test
3. a. IOP
   b. Mydriatic (Tropicamide 1%)
   c. 60-90 minutes later
   d. 8 mmHg is a positive finding

Question 23

Primary ACG Tx

1. Acute ACG = ?
2. Educate pt on what?
3. Rule out what CIs?
   a. What Medication?
   b. Evaluate what else?
4. WHAT IS THE GOAL of Primary ACG Tx?

Answer 23

1. EMERGENCY
2. Seriousness and emergency of condition; Explain Prognosis and Tx including Tx Risks
3. Respiratory, Circulatory, Endocrine, and Hematologic CIs
   a. Medication Allergies: Esp. Sulfa
   b. BP and Pulse
4. NOT to REDUCE IOP, but to CHANGE the ANGLE ANATOMY: IOP will reduce as part of the Process!

Question 24

Acute ACG Tx

1. Step 1: What should be taken first?
   a. What 3 types?
2. Step 2: What should be done next?
   a. Examples?
   b. Are Prostaglandins good?
3. Step 3: Repeated tests (what ones)?

Answer 24

1. Oral Pharmaceuticals
   a. Carbonic Anhydrase Inhibitors, Hyperosmotic Agents, and Anti-Emesis Meds
2. Topical Tx
   a. A2-Agonists, Beta-Blockers, Carbonic Anhydrase Inhibitors, Pilocarpine (IOP

Question 25

Acute ACG Tx (2) 1. Oral Carbonic Anhydrase Inhibitors (DIAMOX) a. Give them how much? b. AVOID what? c. Peak Effect? Duration?? d. CAI and Sulfa Allergies i. Acetazolamide is a Non-bacterial Sulfonamide w/chemical structure and pharmacological activity that's different from what? ii. BOTTOM LINE: In ACUTE ACG, RISK MAY...? e. Clinic Pearl: AVOID using THESE in what Type of Angle Closure?

Answer 25

1. a. 500 mg (2 x 250 mg capsules) b. AVOID SEQUELS as they're EXTENDED RELEASE! c. w/in 2 hrs; 6 hr duration d. i. from Sulfonamide Antimicrobials ii. may outweigh benefit of using Diamox in a Pt w/a History of a "mild" Sulfa Allergy e. Avoid using in TOPIRIMATE or Sulfonamide Induced Angle Closure

Question 26

Acute ACG Tx 1. Hyperosmotic Agents a. Used on a temporary, Short-term basis to do what? b. MOA:? c. Clinical Pearl: Using it on a Pt will make them what? But, if you let them...? d. Most common SIDE EFFECTS of HYPEROSMOTICS?

Answer 26

1. a. to RAPIDLY REDUCE BODILY FLUIDS or RAPIDLY REDUCE HIGH IOP b. Cause Hyperosmolar Blood Stream that causes water to be drawn from surrounding tissues c. VERY THIRSTY; DONT LET THEM DRINK WATER or efficacy is lost d. NAUSEA and VOMITING!

Question 27

Acute ACG Tx 1. 4 Main Drugs? 2. BIGGEST RISK FACTORS? (2: Old peeps...) 3. May provide Pt w/what?

Answer 27

1. a. Glycerol 50% (Osmoglyn) b. Isosorbide 45% (Osmotic) c. Mannitol 20% (IV) d. Urea 30% (IV), 50% (PO) 2. CHF and Subdural Hematoma 3. Anti-emesis (like Compazine) to avoid vomiting if using a hyperosmotic Agent

Question 28

Acute ACG Tx 1. Glycerol a. Max IOP lower after how long? b. Patients cant drink fluids for how long after taking meds? c. "Orange" Flavor: Taste/Texture will do what? d. What is it metabolized into? 2. Isosorbide a. Flavor? b. Medication Not Metabolized into what? c. Safer for what Patients? d. Difficult to find in what country?

Answer 28

1. a. After 1 hr of taking it. b. until 2 hrs after taking it. c. Terrible...Patient will probably VOMIT d. GLUCOSE: AVOID in DIABETICS! 2. a. Vanilla-Mint (usually tolerated in patients) b. Glucose c. diabetics d. in the US

Question 29

Acute ACG Tx: Topical Tx 1. Alpha 2 Agonists? Number of Drops? 2. Beta-Blockers: Number of Drops? 3. Carbonic Anhydrase Inhibitors: drops? 4. Steroids? 5. Instill topical meds: Monitor every what? Give up to how many rounds of the meds? 6. Pilocarpine: (IOP

Answer 29

1. 2 gtts 2. 1 gtt 3. 2 gtts 4. Prednisolone Acetate 1% 5. every 15 minutes; up to 3 rounds of meds q15 min 6. a. Prevent Miotic Events b. 10-30 minutes c. TOPIRIMATE or SULFONIMIDE induced 7. a. TOO SLOWLY to be of any value in ACUTE ANGLE CLOSURE GLAUCOMA! 8. Reducing TM, CB, and Iris INFLAMMATION!; May prevent formation of Synechiae!

Question 30

Acute ACG Tx: Other Topical Tx 1. To Treat Corneal Edema: What 3 things? 2. Cycloplegic Agents? Why dilate? 3. Topamax a. type of drug? b. Associated w/what? Which mimics what? c. Proposed mechanism that causes this? d. HIGH SUSPICION when there's WHAT 2 THINGS? 4. Clinical Pearl: In these CASES, CYCLOPLEGE the Pt to INDUCE what?

Answer 30

1. Topical Hyperosmotics; Topical Glycerin, and Topical Glucose 2. IDK...Listen to lecture at SLIDE 45! 3. a. SULFA drug (oral): Used mainly for Seizure, migraine and Neuropathic Pain b. Secondary Angle Closure; Mimics Primary Angle Closure c. Choroidal Effusion and FORWARD ROTATION of the IRIS-Lens Diaphragm...causing ANTERIOR DISPLACEMENT, which occludes the ANGLE! d. a LARGE MYOPIC SHIFT and BILATERAL OCCLUSION 4. Posterior Rotation of the CB to OPEN the ANGLE

Question 31

Acute ACG Tx: Gonio 1. Corneal Indentation: How do you do it? a. Goal is to do what?

Answer 31

1. 30 seconds on and 30 seconds off | a. Force Aqueous into the Angle which Forces Aqueous OUT OF THE EYE and thus subsequently Open the ANGLE

Question 32

Acute ACG Tx: When can you let them go home for the night? 1. No real guidelines, but... a. Monitor Angle b. Monitor IOP c. Give Topical CAI and Alphagan for Home Use i. Amt? d. When should Pt RTC? e. Refer Pt for what procedure?

Answer 32

1. a. When is the attack broken b.

Question 33

Subacute & Chronic ACG Tx 1. Subacute ACG (intermittent) a. Surgical Treatment (3) 2. Chronic ACG a. Surgical and Medicinal Tx (3) 3. Every case of Primary ACG w/Pupil Block needs what?

Answer 33

1. a. Peripheral Iridotomy; Iridoplasty; Filtering Surgery 2. a. Peripheral Iridotomy; Meds (needed in chronic due to chronic TM damage; Prostaglandins are FIRST choice for Chronic ACG (even in cases of Complete Angle Closure with PAS); Filtering Surgery 3. Laser Peripheral Iridotomy (LPI) as part of management

Question 34

Surgical Procedures: Laser Peripheral Iridotomy (LPI) 1. Purpose of the surgery? 2. Laser a. Argon? b. YAG? c. Procedure typically done w/in what amt of time Post ANGLE Closure after, IOP, Inflammation, and Corneal Edema have been reduced? 3. Basic Overview a. Instill what drugs? b. Laser into what? (Monitor for WHAT?) c. Post-op: What do you monitor? d. What drugs do you give them after?

Answer 34

1. Change Aqueous Dynamics; Open the Angle 2. a. Thermal b. Photodisruptive (can do either of these or both) c. w/in1 wk 3. a. Pilocarpine (to stretch Iris) and Alphagan b. Into the Superior Crypt; Monitor for PLUME c. monitor for IOP Spike and Inflammation d. Alphagan in Office and Steroid gtts QID for 1 week

Question 35

Surgical Procedures: Prophylactic Iridotomy 1. When do they recommend doing it?

Answer 35

1. When ANGLE is NARROW, Chamber is SHALLOW, AND ANY OF THE FOLLOWING EXIST a. Evidence of Appositional Closure b. Evidence of Previous Closure c. Symptoms associated w/Past Closure d. Positive Provocative Test w/evidence of Angle Closure e. Anterior Chamber < 2.0 mm

Question 36

Surgical Procedures: Laser Iridoplasty 1. What Laser is used? 2. Basic overview a. Instill what 2 drugs? b. What do you do in each quadrant in the Periphery? Purpose of it? c. Post-op: Monitor for what? d. What do you give them after the Surgery?

Answer 36

1. Argon (thermal) 2. a. Pilocarpine (stretch the Iris) and Alphagan b. put 6 BURNS in each quadrant in the periphery; Pulls the Iris away from the angle c. for IOP Spike and inflammation d. Alphagan (in office) and Steroid gtts QID x1 wk

Question 37

Secondary Angle Closure with Pupil Block: 1. Causes involve the lens anatomy: (what 5)?

Answer 37

1. Aphakia (can cause vitreous prolapse) 2. Phacolytic 3. Phacomorphic 4. Subluxated Lens 5. Uveitic

Question 38

Primary Angle Closure w/o Pupil Block 1. Plateau Iris a. Gonioscopic description of an eye w/what 2 things? DUE to what? b. Last roll of the Iris is draped over what? 2. Configuration vs. Syndrome: What does the LPI say? 3. Why is there a persistent post-procedure narrow angle?

Answer 38

1. a. Deep Anterior Chamber and Narrow Angle; due to LARGE LAST ROLL of the IRIS b. over FORWARD DISPLACEMENT of the CILIARY PROCESSES 2. LPI is considered Diagnostic; NOT Therapeutic 3. due to anatomical FORWARD POSITION of the Ciliary Processes that keeps the IRIS root in Apposition w/the TM, thus preventing the REPOSITIONING of the IRIS after IRIDOTOMY.

Question 39

Primary Angle Closure w/o Pupil Block 1. Plateau Iris Configuration a. Refers to what? 2. Plateau Iris Syndrome a. Refers to WHAT?

Answer 39

1. PRE-IRIDOTOMY FINDINGS of a NORMAL AC DEPTH, Flat Iris Plane, and a Narrow or CLOSED ANGLE! 2. a. POST-IRIDOTOMY findings of either a SPONTANEOUS or DILATION INDUCED ANGLE CLOSURE in patients w/the Plateau Iris Configuration

Question 40

Secondary Angle Closure w/o Pupil Block 1. ICE's a. Syndromes where Corneal Endothelial Cells do what? b. What does this lead to? c. When Descemet's Membrane contracts, what FORMS? d. Typically it's UNI/BI, and found more in Men/Women most often? e. 3 FORMS of ICE? f. Tx Usually includes what?

Answer 40

1. a. OVER SECRETE b. Leads to Descemet's Membrane Migrating and Extending over the TM c. PAS forms d. Usually UNILATERAL; More often in WOMEN e. Essential Iris Atrophy; Chandler's Syndrome; Cogan-Reese Syndrome f. Usually Penetrating KERATECTOMY (Corneal Transplant) and a FILTERING SURGERY

Question 41

Secondary Angle Closure w/o Pupil Block 1. Essential Iris Atrophy a. Gonio show what? b. Pupil is displaced towards what? c. Iris Shows what?

Answer 41

1. a. Progressive Angle Closure by PAS b. the PAS c. Mild-Moderate ECTROPION, Stromal Atrophy, and Full thickness hole formation opposite the PAS

Question 42

Secondary Angle Closure w/o Pupil Block 1. Chandler's Syndrome a. Changes in iris are what? b. What does the CORNEA present with?

Answer 42

1. a. MILD to ABSENT (Mild CORECTOPIA) | b. Corneal Edema at NORMAL IOP LEVEL

Question 43

Secondary Angle Closure w/o Pupil Block 1. Cogan Reese Syndrome (Iris Nevus) a. Angle changes are the Same as what ICE? b. However, What covers the ANTERIOR IRIS?

Answer 43

1. a. as Essential Iris Atrophy | b. IRIS NEVI (DARK NODULES) cover the Anterior IRIS

Question 44

Secondary Angle Closure w/o Pupil Block 1. Ciliary Block Glaucoma a. AKA? b. What is it? c. What happens to Aqueous flow because of this? d. What does this do to VOLUME INSIDE the VITREOUS CAVITY?

Answer 44

1. a. Malignant Glaucoma and Aqueous Misdirection Syndrome b. Anterior Displacement of the Iris and Ciliary Body (CB and Processes form a TIGHT APPOSITION to the Peripheral Lens and ANTERIOR VITREOUS) c. So Aqueous doesn't flow into AC, but instead flows BACKWARDS into the VITREOUS CAVITY d. Increases it. This PUSHES the LENS and the IRIS TOWARDS the CORNEA and PLACES pressure on the RETINA and the CHOROID

Question 45

Secondary Angle Closure w/o Pupil Block 1. Ciliary Block Glaucoma a. Most common cause of this is what? b. Classic Sign of Ciliary Block Glaucoma Development? Tx: c. Unresponsive to what therapies? d. Main form of Tx? e. Surgical Options?

Answer 45

1. a. Complication from Glaucoma Surgery b. Swelling of Ciliary Body, Anterior Vitreous Displacement, or TUMOR c. conventional medical and surgical glaucoma therapies d. Atropine 1% BID (indefinitely), Topical Steroids, Aq. Suppressants, Possibly Acetazolamide! e. Vitrectomy and Lensectomy; or Chandler's Procedure: Vitreous Aspiration w/Gas Reformation of the AC or YAG Laser disruption of the Anterior Vitreous Face