Review of Angle closure
Glaucomas
Fritz Allen MD
Visionary Ophthalmology
November 10th 2013
Angle-Closure Glaucomas



Acute Primary Angle-Closure Glaucomas



Neovascular Glaucoma

2
Detection

Gonioscopy
Pentacam/ Anterior segment
OCT
Gonioscopy
Indications




Overcomes problem of total internal reflectivity to see angle
structures



Indirect goniosc...
Gonioscopy



Identification of angle recession, foreign bodies, abnormal
pigmentation, tumors, angle neovascularization,...
Gonioscopy
Contraindications




Inability of patient to cooperate



Corneal abrasion or disease precluding
applicatio...
Gonioscopy

Goldmann type




Goldmann lens requires clear fluid to fill space between cornea and
goniolens



Lens is ...
Gonioscopy

Complications



Corneal abrasion




Considerations in interpretation



Normal angle landmarks (best vie...
Gonioscopy

9
Gonioscopy

10
Direct
Gonioscopy
Indirect

11
Gonioscopy

12
Gonioscopy

13
Gonioscopy

Drawing showing gonioscopic view
in combination with microscopic
cross-section. Corneal wedge
(arrow)

Drawing...
Gonioscopy

15
Drawing by Lee Allen
Gonioscopy

16
Gonioscopy

17
Gonioscopy

18
Gonioscopy

19
Pentacam
Pentacam
Pentacam
Pentacam: open angle
Pentacam: narrow angle
Pentacam

 The Anterior Chamber Volume (ACV) has been fond to
good screening tool for the diagnosis of narrow angles.
 W...
Acute Primary AngleClosure Glaucoma
Etiology



Physiologic pupillary block




Excessive iris-lens apposition impedes ...
Acute Primary-Angle
Closure Glaucoma
 Signs

27











High IOP
Mid dilated, sluggish pupil
Corneal epitheli...
Acute Primary AngleClosure Glaucoma
Risk factors





Family history of angle-closure



Older age



Female gender

...
Acute Primary AngleClosure Glaucoma
Medical therapy options



To lower the IOP and allow clearing of corneal edema in
pr...
Acute Primary AngleClosure Glaucoma


Deformation of cornea with cotton tip applicator or Indentation
gonioscopy occasion...
Acute Primary AngleClosure Glaucoma
Complications




Complications of laser iridotomy



Posterior synechiae



Mioti...
Acute Primary AngleClosure Glaucoma
Disease-related complications





Corneal decompensation



Sectoral iris atrophy...
Acute Primary AngleClosure Glaucoma

Glaukomflecken under the anterior lens
capsule after an attack of acute angle
closure...
Acute Primary AngleClosure Glaucoma
Pre Iridotomy

Post iridotomy

34
Photos courtesy of Jeff Henderer, MD
Neovascular Glaucoma

History






Markedly reduced vision (usual)



Diabetes



35

Pain, photophobia (usual)

Hyp...
Neovascular Glaucoma

Epidemiology




CRVO



PDR



Post cataract extraction, vitrectomy


Carotid occlusive diseas...
Neovascular Glaucoma
Features: Early













37



Tufts of new vessels at pupillary margin
Fine vessels ...
Neovascular Glaucoma
Risk factors




Retinal hypoxia

Disease-related complications




Absolute glaucoma with blindn...
Neovascular Glaucoma

Neovascularization
of the iris and angle

39
Photo courtesy of Teresa Chen, MD
Review of angle closure glaucomas, By Fritz Allen, MD
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Review of angle closure glaucomas, By Fritz Allen, MD

  1. 1. Review of Angle closure Glaucomas Fritz Allen MD Visionary Ophthalmology November 10th 2013
  2. 2. Angle-Closure Glaucomas  Acute Primary Angle-Closure Glaucomas  Neovascular Glaucoma 2
  3. 3. Detection Gonioscopy Pentacam/ Anterior segment OCT
  4. 4. Gonioscopy Indications   Overcomes problem of total internal reflectivity to see angle structures  Indirect gonioscopy (e.g., Goldmann or four mirror lens)  Essential diagnostic tool in glaucoma (viewing the iridocorneal angle)  Most common cause of incorrect diagnosis is omission of gonioscopy  Omission causes overlooking secondary glaucomas and other glaucomas  Periodically performed can detect secondary emergence of mixed mechanism 4
  5. 5. Gonioscopy  Identification of angle recession, foreign bodies, abnormal pigmentation, tumors, angle neovascularization, angle synechiae  Glaucoma treatment in the angle  Laser trabeculoplasty  Goniosynechialysis  Treatment and evaluation of internal ostium of trabeculectomy site  Gonioplasty/iridoplasty 5
  6. 6. Gonioscopy Contraindications   Inability of patient to cooperate  Corneal abrasion or disease precluding application of corneal lens  Pre-procedure evaluation  Indirect gonioscopy View angle with slit-lamp using a gonioscopic lens  Technique  6 Indirect gonioscopy   Produces inverted image 180 away from origination  Two types of lenses are in common use
  7. 7. Gonioscopy Goldmann type   Goldmann lens requires clear fluid to fill space between cornea and goniolens  Lens is brought toward patient’s eye and tipped forward quickly enough to trap the clear fluid 4 mirror type    Requires only drop of anesthetic  Indentation gonioscopy can be performed  7 Rests solely on cornea / tear film Technique to differentiateappositional and synechial angle-closure
  8. 8. Gonioscopy Complications  Corneal abrasion   Considerations in interpretation  Normal angle landmarks (best viewed with parallelepiped method)   8 Prevention: moist cornea, topical anesthesia, minimize movement of lens on cornea Anterior to posterior: cornea, Schwalbe’s line, non-pigmented trabecular meshwork, pigmented trabecular meshwork, scleral spur, ciliary band, iris root
  9. 9. Gonioscopy 9
  10. 10. Gonioscopy 10 Direct
  11. 11. Gonioscopy Indirect 11
  12. 12. Gonioscopy 12
  13. 13. Gonioscopy 13
  14. 14. Gonioscopy Drawing showing gonioscopic view in combination with microscopic cross-section. Corneal wedge (arrow) Drawing by Lee Allen 14
  15. 15. Gonioscopy 15 Drawing by Lee Allen
  16. 16. Gonioscopy 16
  17. 17. Gonioscopy 17
  18. 18. Gonioscopy 18
  19. 19. Gonioscopy 19
  20. 20. Pentacam
  21. 21. Pentacam
  22. 22. Pentacam
  23. 23. Pentacam: open angle
  24. 24. Pentacam: narrow angle
  25. 25. Pentacam  The Anterior Chamber Volume (ACV) has been fond to good screening tool for the diagnosis of narrow angles.  With ACV of 110 mm3 as cut off : sensitivity of 88.32%, specificity of 90.62%, positive predictive value 92.7  Any patient with an ACV of <110mm3 had 9.42 time chance of having narrow angla on gonioscopy.
  26. 26. Acute Primary AngleClosure Glaucoma Etiology  Physiologic pupillary block   Excessive iris-lens apposition impedes flow of aqueous from PC to AC, elevating PC aqueous pressure  Secondary forward bowing of peripheral iris results in occlusion of the TM Features  Symptoms    Blurred vision  Colored haloes around lights  26 Acute onset of brow ache, eye pain Nausea and vomiting
  27. 27. Acute Primary-Angle Closure Glaucoma  Signs 27          High IOP Mid dilated, sluggish pupil Corneal epithelial edema Congested episcleral and conjunctival vessels Shallow AC AC inflammation Appositional angle-closure Iris bombe Glaukomflecken and sector iris atrophy – indicators of previous bouts of acute-closure glaucoma
  28. 28. Acute Primary AngleClosure Glaucoma Risk factors    Family history of angle-closure  Older age  Female gender  Age-related cataract (lens swelling)  28 Hyperopia Asian ethnicity
  29. 29. Acute Primary AngleClosure Glaucoma Medical therapy options  To lower the IOP and allow clearing of corneal edema in preparation for laser iridotomy    Alpha2-adrenergic agonists  CAIs – topical, oral, IV  Miotics – 1-2% pilocarpine after IOP starts to normalize  Prostaglandin analogues  Hyperosmotic agents  29 Beta-adrenergic antagonists Topical corticosteroids
  30. 30. Acute Primary AngleClosure Glaucoma  Deformation of cornea with cotton tip applicator or Indentation gonioscopy occasionally opens the angle  Topical glycerin or epithelial removal may be necessary to enable visualization of the chamber angle Surgical therapy    30 Laser peripheral iridotomy–Nd:YAG and/or argon Cristallin Lens extraction
  31. 31. Acute Primary AngleClosure Glaucoma Complications   Complications of laser iridotomy  Posterior synechiae  Miotics, especially strong miotics, may increase pupillary block  Formation of PAS  31 Perform laser iridotomy as soon as possible
  32. 32. Acute Primary AngleClosure Glaucoma Disease-related complications    Corneal decompensation  Sectoral iris atrophy  Posterior synechiae  Cataract formation  Optic nerve damage  32 Residual stage of angle-closure glaucoma Retinal vascular occlusion
  33. 33. Acute Primary AngleClosure Glaucoma Glaukomflecken under the anterior lens capsule after an attack of acute angle closure. These lens changes are caused by necrosis of the lens epithelium. 33
  34. 34. Acute Primary AngleClosure Glaucoma Pre Iridotomy Post iridotomy 34 Photos courtesy of Jeff Henderer, MD
  35. 35. Neovascular Glaucoma History    Markedly reduced vision (usual)  Diabetes  35 Pain, photophobia (usual) Hypertension, arteriosclerosis
  36. 36. Neovascular Glaucoma Epidemiology   CRVO  PDR  Post cataract extraction, vitrectomy  Carotid occlusive disease    36 Particularly with breached posterior capsule May have normal or low IOP CRAO
  37. 37. Neovascular Glaucoma Features: Early            37  Tufts of new vessels at pupillary margin Fine vessels crossing scleral spur Features: Late Very high IOP Conjunctival injection Corneal edema Florid iris neovascularization with ectropionuveae Fibrovascular membrane over iris and angle structures Variable synechial angle-closure With total angle closure, there can be minimal neovascularization of iris, and with pigmented Schwalbe's line, on gonioscopy can be mistaken for OAG AC cells and flare
  38. 38. Neovascular Glaucoma Risk factors   Retinal hypoxia Disease-related complications   Absolute glaucoma with blindness  Intractable pain Patient instructions    38 Medication and surgical discussion Referral for PRP, surgical intervention, and/or cyclodestructive procedure
  39. 39. Neovascular Glaucoma Neovascularization of the iris and angle 39 Photo courtesy of Teresa Chen, MD

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