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![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](https://image.slidesharecdn.com/aisgsiglasemeioticaglaucomaangolostrettodottnicolacanalibrescia2016-190303213958/75/Aisg-sigla-semeiotica-glaucoma-angolo-stretto-dott-nicola-canali-brescia-2016-52-2048.jpg)
![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](https://image.slidesharecdn.com/aisgsiglasemeioticaglaucomaangolostrettodottnicolacanalibrescia2016-190303213958/75/Aisg-sigla-semeiotica-glaucoma-angolo-stretto-dott-nicola-canali-brescia-2016-53-2048.jpg)
![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](https://image.slidesharecdn.com/aisgsiglasemeioticaglaucomaangolostrettodottnicolacanalibrescia2016-190303213958/75/Aisg-sigla-semeiotica-glaucoma-angolo-stretto-dott-nicola-canali-brescia-2016-54-2048.jpg)
![Gonioscopy technique in
narrow angles
Recommendation
Careful gonioscopy, performed under ideal
conditions (dim ambient light, narrow light beam
from the slit lamp, use of compression gonioscopy)
is fundamental to assess the presence of angle
closure in patients suspected of having narrow
angles [Consensus].
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.](https://image.slidesharecdn.com/aisgsiglasemeioticaglaucomaangolostrettodottnicolacanalibrescia2016-190303213958/75/Aisg-sigla-semeiotica-glaucoma-angolo-stretto-dott-nicola-canali-brescia-2016-83-2048.jpg)
Uploaded byNicola Canali
Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016
This document discusses angle-closure glaucoma, including: 1. It defines angle-closure glaucoma and classifies it based on etiology, with the most important criterion being the presence or absence of pupil block. 2. It describes the three most common presentations of primary angle-closure glaucoma: acute angle closure, narrow angle at risk of acute closure with normal IOP, or chronic angle closure glaucoma. 3. Gonioscopy is identified as a key examination for diagnosing angle-closure glaucoma by allowing visualization of the anterior chamber angle.
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Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016
- 2. Corso AISG-SIGLA Glaucoma daChiusura d’Angolo Template a cura di Giorgio Marchini
- 5. In ambito medico,la semeiotica (dal greco σημεῖον, semèion, che significa "segno", e dal suffisso -iké, "relativo a") sintomi segni L'etimologia del termine è identica a quella di semiotica ma, per consuetudine, la parola "semeiotica" viene utilizzata solo per definire quella medicina sintomi malattia diagnosi In senso lato, (radiologia, elettrocardiografia, endoscopia, ecc). σημεῖον, semèion
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- 9. laucoma rimario dahiusura d’ ngolo (angolo potenzialmente «occludibile», Occhio a rischio di GPCA) - da «blocco posteriore» (es. gl. maligno) - da «trazione anteriore» (es. gl. neovascolare) σημεῖον, semèion
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- 13. N.B. GPCA cronicizzato= attacco acuto non risolto σημεῖον, semèion
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- 17. • Test diVan Herick • 5 classi (gradi da 4 a 0) • Screening per occhi a rischio di chiusura • Non sostituisce la gonioscopia
- 18. • Angoli nonpericolosi: grado 4 e grado 3 • Attenzione al grado 2 • Angoli pericolosi: grado 1 e grado 0 N.B. Grado 2: gonioscopia dinamica!
- 22. - raggio dicurvatura più corto - necessità di mezzo accoppiante - raggio di curvatura più lungo - appoggiata direttamente
- 23. - raggio dicurvatura più corto - necessità di mezzo accoppiante - raggio di curvatura più lungo - appoggiata direttamente
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- 25. Strutture angolari • Schwalbe •Trabecolato anteriore e posteriore • Sperone sclerale • Banda ciliare
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- 32. Meccanismo dichiusura - blocco pupillare - senza blocco pupillare Chiusura apposizionale o anatomica Ruolo del cristallino
- 38. PREDISPOSING FACTORS • Relativeanterior position of iris-lens diaphragm • Shallow anterior chamber • Narrow entrance to angle Anatomical • Physiological pupillary block Physiological
- 39. PHYSIOLOGICAL PUPILLARY BLOCK 1.Iris has large arc of contact with anterior surface of lens 2. Resistance to aqueous flow from posterior to anterior chamber (relative pupil block) 3. Pupil dilates, peripheral iris becomes more flaccid and pushed anteriorly 4. Iris lies against trabecular meshwork impede aqueous humor drainage ↑ IOP
- 40. SYMPTOMS 1. Rapidly progressiveimpairment of vision 2. Painful eye 3. Red eye 4. Nausea, vomiting 5. Photophobia 6. Haloes, transient blurring – indicate previous intermittent attacks 7. Hx of similar attacks in the past, aborted by sleep ** CACG: usually asymptomatic due to slow onset of disease
- 41. SIGNS 1. Reduced visualacuity 2. Cornea cloudy and oedematous 3. Pupil oval, fixed and moderately dilated 4. Ciliary injection 5. Eye feels hard on palpation 6. Elevated IOP (50-100 mmHg) 7. Narrow chamber angle with peripheral iridocorneal contact 8. Aqueous flare and cells 9. Gonioscopy – complete peripheral iridocorneal contact 10. Ophthalmoscopy – optic disc odema and hyperaemia
- 43. ACUTE CONGESTIVE ANGLECLOSURE GLAUCOMA • Due to rapid ↑ in IOP • Defined as: At least 2 of the following SYMPTOMS: • Ocular pain • Nausea/ vomiting • Hx of intermittent BOV with halos Plus 3 of the following SIGNS • IOP > 21mmHg • Conjunctival injection • Corneal epithelial edema • Mid-dilated non reactive pupil • Shallower chamber in presence of occlusion
- 44. Severe edematous cornea, Dilated, unreactive, vertically oval pupil Ciliaryinjection, Shallow anterior chamber Complete angle closure
- 45. DIFFERENTIAL DIAGNOSIS Usually blurred Markedly blurred Slightly blurred No effecton vision Vision Moderate to severe SevereModeratevariablePain Watery or purulent NoneNoneModerate to copious (mucopurulent ) Discharge CommonUncommonCommonExtremely common Incidence Corneal trauma or infection Acute congestive glaucoma Acute iridocyclitis Acute conjunctivitis
- 46. Organisms found only in cornealulcers due to infection No organismsNo organismsCausative organisms Smear NormalElevatedNormalNormalIntraocular pressure NormalNonePoorNormalPupillary light response NormalSemidilated and fixed SmallNormalPupil size Change in clarity related to cause HazyUsually clearClearCornea DiffuseDiffuseMainly circumcorneal Diffuse, more toward fornices Conjunctival injection
- 47. CX AND SEQUALAE 1.Peripheral anterior synechiae (PAS) – the peripheral iris adheres to the posterior corneal surface in the trabecular area and blocks the outflow of aqueous 2. Cataract- swelling of the lens and cataract formation – this may push the iris even further anteriorly; this increases the pupillary block 3. Atrophy of the retina and optic nerve - glaucomatous cupping of the optic disc and retinal atrophy 4. Absolute glaucoma - eye is stony hard, sightless, painful
- 48. SECONDARY ANGLE CLOSURE GLAUCOMA •Angle-closure secondary to a variety of ocular disorders – Lens abnormalities (thick cataract) – Lens dislocation – Inflammation (uveitis, scleritis, extensive retinal photocoagulation) • Signs and symptoms – Same as PACG
- 50. Ultrasound biomicroscopy • Allowsto visualize iris,iris root,CS junction,ciliary body,lens. • To elucidate the mechanism of angle closure
- 51. Ocular manifestations • Symptoms: Decreasedvision Halos around lights frontal headache Ocular pain nausea and vomiting
- 52. 1. Acute congestiveglaucoma 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
- 53. 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
- 54. 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
- 55. Diagnosis • Primary AngleClosure Glaucoma – Acute Angle Closure • Definition: IOP rises rapidly as a result of relatively sudden blockage of the TM by the iris • Symptoms: – Ocular pain – Headache – Blurred vision – Rainbow-colored halos around lights – Nausea – Vomitting
- 56. Diagnosis • Signs: – VA6/60-HM – High IOP – Congested episcleral and conjuctival blood vessels – Corneal edema – Shallow AC (aqueous flares and cells) – Iris bombé – Mid-dilated, sluggish and irregularly shaped pupil – Glaukomflecken
- 57. Diagnosis – Subacute orIntermittent Angle Closure • Blurred visions, halo • Mild pain by elevated IOP • IOP is normal between episodes • May to chronic angle closure glaucoma or acute attack if not resolve spontaneously
- 58. Diagnosis – Chronic AngleClosure • May develop after acute attack in which synechial closure persists • Or after AC chamber close gradually or IOP slowly rises (Creeping Angle) • Resembles open angle glaucoma due to: – Lack of symptoms – Modest IOP elevation – Optic nerve damage – Characteristic VF loss
- 59. Diagnosis • Clinical Evaluation: –History – Ocular Examination – Gonioscopy – Optic Nerve – Visual Field Test
- 60. Physical findings inacute angle-closure glaucoma with pupillary block 3/3/2019 • Findings during an acute attack of angle-closure glaucoma • Two of the following symptom sets: Periorbital or ocular pain Diminished vision Specific history of rainbow haloes with blurred vision IOP higher than21 mmHg • plus three of the following findings: Ciliary flush Corneal edema Shallow anterior chamber Anterior chamber cell and flare Mid-dilated and sluggishly reactive pupil Closed angle on gonioscopy Diminished outflow facility Hyperemic and swollen optic disc Constricted visual field
- 61. Acute congestive angle-closureglaucoma • Severe corneal oedema • Complete angle closure (Shaffer grade 0) • Dilated, unreactive, vertically oval pupil • Shallow anterior chamber • Ciliary injection Signs
- 62. 3/3/2019 • Findings suggestingprevious episodes of acute angle- closure glaucoma Peripheral anterior synechiae Posterior synechiae to lens Glaukomflecken Sector or generalized iris atrophy Optic nerve cupping and/ or pallor Visual field loss Diminished outflow facility
- 63. Differential diagnosis ofacute angle-closure glaucoma 3/3/2019 • Evidence of compromised angle on gonioscopy or shallow anterior chamber Ciliary block glaucoma (aqueous misdirection or malignant glaucoma) Neovascular glaucoma Iridocorneal endothelial syndrome Plateau iris syndrome with angle closure Secondary angle closure with pupillary block (e.g., posterior scleritis) Cilio-choroidal detachments (bilateral)
- 64. 3/3/2019 • High-pressure open-angleglaucomas masquerading as acute angle closure Glaucomatocyclitic crisis Herpes simplex keratouveitis Herpes zoster uveitis Sarcoid uveitis Pigmentary glaucoma Exfoliative glaucoma (may have associated angle closure)
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- 69. Canadian Ophthalmological Society Evidence-based ClinicalPractice Guidelines for the Management of Glaucoma in the Adult Eye
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- 71. Angle-closure glaucomas • Themost useful classification for angle-closure glaucoma is based upon etiology. • The most important criterion is the presence or absence of pupil block, with further sub- classification into primary and secondary mechanisms. • The prevalence of PACG varies significantly among different ethnic groups. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 72. Angle-closure glaucomas • Patientswith PACG commonly present with 1 of 3 possible scenarios: – acute angle closure, – narrow angle at risk of acute closure with normal IOP, or – creeping angle closure with or without elevated IOP. • Patients may present with what appears to be chronic OAG, but angle closure is subsequently discovered on gonioscopy. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 73. Pupil Primary Examplesof secondary Pupil block Primary acute or chronic angle closure • Posterior synechiae • Silicone oil • AC IOL without iridectomy • Lens subluxation or lens swelling Non-pupil block Plateau iris syndrome • Posterior mechanisms − Choroidal tumour − Choroidal effusion o medication-induced (sulfonamides) o spontaneous − Ciliary block − Lens-induced • Anterior mechanism − Angle neovascularization − Iritis − ICE syndrome − Epithelial down growth Classification of angle closure based on functional cause Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 74. Risk factors fordevelopment of primary angle closure • Axial hyperopia • Family history of angle closure • Advancing age • Female gender • East Asian ethnicity • Inuit ethnicity • Latino ethnicity • Shallow peripheral anterior chamber • Short axial length eyes Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 75. Acute angle closure: Signsand symptoms Symptoms include: • Severe pain • Headache • Nausea and vomiting • Blurred vision • Halos around lights • Conjunctival injection Signs include: • Ciliary flush • Corneal edema • Fixed mid-dilated pupil • Shallow anterior chamber • Elevated IOP • Sometimes glaukomflecken • The angle is observed to be closed on gonioscopic examination Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 76. Narrow angle atrisk of closure (angle-closure suspect) • A patient would be considered an angle-closure suspect if he or she had iridotrabecular contact on gonioscopy without PAS, and without GON and VF damage. • There are usually no symptoms associated with a narrow angle; however, intermittent angle closure is possible. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 77. Narrow angle atrisk of closure (angle-closure suspect) (cont’d) • Signs of narrow angle at risk of closure include: – Shallow peripheral anterior chamber and an open angle on gonioscopy. – Trabecular meshwork, while still visible, is almost or partially occluded. • The IOP is not elevated. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 78. Creeping angle closure •There are no symptoms associated with creeping angle closure. • Signs include: – normal or elevated IOP, – PAS in portions of the angle, – possible optic disc damage, and – possible glaucomatous VF defects. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 79. Diagnosis of Angle ClosureGlaucomas
- 80. Diagnosis of angle closureglaucoma • Diagnosis requires a detailed history and physical exam. • History must include: – whether the pupil has ever been pharmacologically dilated, – medication history to elicit the use of medications that may dilate the pupil, such as those: o with anticholinergic effects/side effects o that counteract the iris sphincter muscle o with sympathomimetic effects that work on the iris dilator muscle, o that may cause anterior movement of the lens iris diaphragm (e.g., sulfonamides) – family history of acute glaucoma or previous laser iridotomy in a first-degree relative, and – personal history indicative of symptoms of previous intermittent attacks of angle closure. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 81. Diagnosis of angle closureglaucoma • On examination, it is important to note: – visual acuity – refractive error – pupil size and reaction – presence of corneal edema – anterior chamber depth centrally and peripherally – presence of iris or angle new vessels indicative of neovascularization – presence of anterior chamber inflammation – IOP – lens appearance Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 82. Diagnosis of angle closureglaucoma • Gonioscopy of both eyes is mandatory to assess the depth of the anterior chamber and the presence of PAS (compression gonioscopy with a Zeiss-type lens is very useful in differentiating PAS from apposition). Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
- 83. Gonioscopy technique in narrowangles Recommendation Careful gonioscopy, performed under ideal conditions (dim ambient light, narrow light beam from the slit lamp, use of compression gonioscopy) is fundamental to assess the presence of angle closure in patients suspected of having narrow angles [Consensus]. Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of glaucoma in the adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.