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ANGLE CLOSURE GLAUCOMA

DR RAJVIN SAMUEL
• Angle closure – Iridotrabecular apposition
/adhesion
obstruction to aqueous outflow
Raised Intraocular pressure.
• Anato...
Stages in Natural history
• 1 Primary angle-closure suspect (PACS) • Gonioscopy shows
posterior meshwork ITC in three or m...
Risk Factors
•
•
•
•
•
•
•

Positive family history for angle closure
Age over 40-50 yrs
Women
History of Angle closure sy...
• Relative Pupillary block • Failure of
aqueous flow through the mid dilated pupil
leads to a pressure differential betwee...
• Non-pupillary block relating to the iris • Specific
anatomical factors include plateau iris (anteriorly
positioned cilia...
Gonioscopic examination
•

To determine topography of anterior chamber angle –angle width,level of iris
insert,shape of pe...
Anatomy of angle
Slit lamp grading or PACD
• Van herrick method:
grade 0 – Iridocorneal contact ,
grade 1- PACD < ¼ CT
grade 2- pacd [1/4 t...
Ultrasound biomicroscopy
• Allows to visualize iris,iris root,CS
junction,ciliary body,lens.
• To elucidate the mechanism ...
Ocular manifestations
• Symptoms:
Decreased vision
Halos around lights
frontal headache
Ocular pain
nausea and vomiting
1. Acute congestive glaucoma
Elevated IOP risen rapidly
Conjunctival congestion
Corneal epithelial /stromal edema
Shallow ...
2. Chronic presentation
• ‘Creeping’ angle-closure [gradual band-like anterior
advance of the apparent insertion of the ir...
3 Resolved acute (post-congestive) angle
closure
•

Folds in Descemet membrane (if IOP has been reduced
rapidly), optic ne...
Sequence of events:
• Acute angle closure:
sudden ,circumferential ,iridotrabecular
apposition-rapid severe rise in IOP
• ...
Provocative tests
• Pharmacological test:
pupillary block mechanism in mid dilated
state ,increased tension of iris .
-Per...
• Paraphysiological test :
Dark room prone test – pupil dilates in
dark,lens moves forwards in prone.
- Patient sits for 3...
Initial management of PACG ATTACK
Immediately on attack
Pilocarpine 2%
B-blocker
Apraclonidine
Topical corticosteroid
IV o...
Attack not broken

IV Osmotic if not already given

Clear Cornea

Laser iridectomy
,iridoplasty

Cloudy cornea

Laser irid...
Peripheral laser iridotomy :
• A procedure ,where hole is made in iris periphery
allowing aqueous to drain from PC into TM...
Surgical peripheral iridectomy
• Removal of iris tissue by knife or scissors
• 2-3 mm peripheral corneal incision in
super...
Argon laser iridoplasty
• Aim to shrink and flatten iris tissue without damage
• Placement of circumferential ring of non ...
Goniosynechialysis
• It involves stripping of peripheral anterior
synechiae using an Irrigation cyclodialysis
spatula / fl...
Lens extraction
Removal of lens with or without opacity due to
lens size / malposition.
Best outcomes with small incision ...
Trabeculectomy
• Trabeculectomy lowers IOP - creating a fistula,
to allow aqueous outflow from the anterior
chamber to the...
Angle  closure  glaucoma
Angle  closure  glaucoma
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Angle closure glaucoma

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Angle closure glaucoma

  1. 1. ANGLE CLOSURE GLAUCOMA DR RAJVIN SAMUEL
  2. 2. • Angle closure – Iridotrabecular apposition /adhesion obstruction to aqueous outflow Raised Intraocular pressure. • Anatomical features : shallow AC Thicker lens Increased anterior lens curve Shorter Axial length Smaller corneal diameter Increased ratio of lens thickness to axial length Occludable Angle: When Pigmented trabecular meshwork is not visible without indentation or manipulation in at least 3 or 4 quadrants
  3. 3. Stages in Natural history • 1 Primary angle-closure suspect (PACS) • Gonioscopy shows posterior meshwork ITC in three or more quadrants but no PAS. • Normal IOP, optic disc and visual field. 2 Primary angle-closure (PAC) • Gonioscopy shows three or more quadrants of ITC with raised IOP and/or PAS, or excessive pigment smudging on the TM. • Normal optic disc and field. 3 Primary angle-closure glaucoma (PACG) • Gonioscopy shows ITC in three or more quadrants. • Optic neuropathy. • ITC –iridotrabecular contact , PAS – Peripheral anterior synechiae
  4. 4. Risk Factors • • • • • • • Positive family history for angle closure Age over 40-50 yrs Women History of Angle closure symptoms Hyperopia Pseudoexfoliation Racial group Asians [far eastern]
  5. 5. • Relative Pupillary block • Failure of aqueous flow through the mid dilated pupil leads to a pressure differential between the anterior and posterior chambers, with resultant anterior bowing of the lax iris [Iris bombe] blocks trabecular meshwork and iridolenticular contact
  6. 6. • Non-pupillary block relating to the iris • Specific anatomical factors include plateau iris (anteriorly positioned ciliary processes), and a thicker or more anteriorly-positioned iris. • Plateau iris configuration is characterized by a flat central iris plane in association with normal central anterior chamber depth. The angle recess is very narrow, with a sharp iris angulation over anteriorly positioned and/or orientated ciliary processes (Fig. 10.43). • Plateau iris syndrome describes the occurrence of angle-closure despite a patent iridotomy in a patient with morphological plateau iris.
  7. 7. Gonioscopic examination • To determine topography of anterior chamber angle –angle width,level of iris insert,shape of peripheral iris,apposition/synechiae. • Shaffer grading: Grade 4 (35–45°) is the widest angle,[ in which the ciliary body can be visualized with ease] Grade 3 (25–35°) is an open angle [ in which at least the scleral spur can be identified] Grade 2 (20°) is a moderately narrow angle [in which only the trabeculum can be identified Grade 1 (10°) is a very narrow angle [ in which only Schwalbe line, and trabeculum, can be identified. Slit angle [ no obvious iridocorneal contact but no angle structures can be identified. Grade 0 (0°) is a closed angle due to iridocorneal contact and is recognized by the inability to identify the apex of the corneal wedge. Indentation gonioscopy will distinguish ‘appositional’ from ‘synechial’ angle closure
  8. 8. Anatomy of angle
  9. 9. Slit lamp grading or PACD • Van herrick method: grade 0 – Iridocorneal contact , grade 1- PACD < ¼ CT grade 2- pacd [1/4 to 1/2 ] CT grade 3- not occludable > ½ CT
  10. 10. Ultrasound biomicroscopy • Allows to visualize iris,iris root,CS junction,ciliary body,lens. • To elucidate the mechanism of angle closure
  11. 11. Ocular manifestations • Symptoms: Decreased vision Halos around lights frontal headache Ocular pain nausea and vomiting
  12. 12. 1. Acute congestive glaucoma Elevated IOP risen rapidly Conjunctival congestion Corneal epithelial /stromal edema Shallow or flat peripheral AC mid dilated [vertical oval] pupil absent /sluggish pupil reaction Fellow eye generally shows an occludable angle
  13. 13. 2. Chronic presentation • ‘Creeping’ angle-closure [gradual band-like anterior advance of the apparent insertion of the iris]. From deepest part of the angle and spreads circumferentially. • • Episodic (intermittent) ITC is associated with the formation of discrete PAS, individual lesions having a pyramidal (‘saw-tooth’) appearance. • Disc cupping /nerve fibre defects with or without visual field defect
  14. 14. 3 Resolved acute (post-congestive) angle closure • Folds in Descemet membrane (if IOP has been reduced rapidly), optic nerve head congestion and choroidal folds. • Later iris atrophy [spiral-like configuration], irregular pupil, posterior synechiae and glaukomflecken • Iris torsion
  15. 15. Sequence of events: • Acute angle closure: sudden ,circumferential ,iridotrabecular apposition-rapid severe rise in IOP • Intermittent angle closure : Self limiting episodes of ITC ,milder signs & symptoms of former • Creeping angle closure: slowly progressive ITC –Elevated IOP • Chronic angle closure : irreversible ,iridotrabecular adhesion ,asymptomatic unless significant raised IOP.
  16. 16. Provocative tests • Pharmacological test: pupillary block mechanism in mid dilated state ,increased tension of iris . -Performed with short acting mydriatic [phenylephrine eye drops] -if test proves positive –acute attack may be triggered
  17. 17. • Paraphysiological test : Dark room prone test – pupil dilates in dark,lens moves forwards in prone. - Patient sits for 30 minutes in dark with head prone ,no sleeping - IOP checked rapidly ,positive if increases by 8 mm Hg
  18. 18. Initial management of PACG ATTACK Immediately on attack Pilocarpine 2% B-blocker Apraclonidine Topical corticosteroid IV osmotic agent /acetazolamide Corneal indentation using 4 mirror lens Leave patient supine to allow lens move back in position If patient in pain Attack broken Pupil constricted IOP lowered Corneal clearing Topical ketorolac , systemic pain medication If patient is vomiting Intramuscular metoclopramide If patient comfortable laser prophylactic iridectomy in fellow eye 60 minutes Topical pilocarpine 2% Topical corticosteroids Laser prophylactic iridectomy
  19. 19. Attack not broken IV Osmotic if not already given Clear Cornea Laser iridectomy ,iridoplasty Cloudy cornea Laser iridoplasty Attack not broken Surgery
  20. 20. Peripheral laser iridotomy : • A procedure ,where hole is made in iris periphery allowing aqueous to drain from PC into TM Helps eliminate high aqueous pressure behind iris and iris falls back. Done using Nd:YAG laser ,150-200 microns size 3-6 mj of power based on thickness Topical pilocarpine 30 mins before laser therapy, identify crypt in iris and create opening . Post op steroids and antiglaucoma meds Examine patency and size of iridotomy with gonioscopy
  21. 21. Surgical peripheral iridectomy • Removal of iris tissue by knife or scissors • 2-3 mm peripheral corneal incision in superotemporal site. • Alternatively ,conjunctival peritomy and scleral limbus incision ,nylon sutures wound closure • Externalised iris piece held with toothed forceps , incised with fine scissors.
  22. 22. Argon laser iridoplasty • Aim to shrink and flatten iris tissue without damage • Placement of circumferential ring of non penetrating contraction burns at far iris periphery – widen angle,contract stroma • Evenly spaced applications [4-10 burns /quadrant , 200500 microns large 0.2-0.5 sec , low powered [200-400 mW] ,central button of goniolens. • Energy is defocussed so can be given in cloudy cornea also
  23. 23. Goniosynechialysis • It involves stripping of peripheral anterior synechiae using an Irrigation cyclodialysis spatula / flat iris spatula. • Viscoelastics used to deepen the anterior chamber .
  24. 24. Lens extraction Removal of lens with or without opacity due to lens size / malposition. Best outcomes with small incision phaco.
  25. 25. Trabeculectomy • Trabeculectomy lowers IOP - creating a fistula, to allow aqueous outflow from the anterior chamber to the sub-Tenon space. The fistula is protected or ‘guarded’ by a superficial scleral flap • When medical therapy has failed to achieve adequate control of IOP.

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