Angle closure glaucoma

1. ANGLE CLOSURE
GLAUCOMA
-Anira Iqbal
Batch 2011

2. CLASSIFICATION
Angle-closure
Glaucoma
Primary Secondary
Acute (AACG)
Chronic (CACG)

3. TERMINOLOGIES
Primary Angle
Closure Disease :
Narrow angle of AC 
Apposition of
peripheral iris against
TM  Obstruction of
aqueous outflow
Primary Angle
Closure Glaucoma :
+ Optic Disc(OD)
Changes
+ Visual field

4. RISK FACTORS
Demographic Anatomic
Age – 60 to 70 y/o
Gender – M:F 1:3
Heredity – Anatomic RF
Race – SE Asians, Chinese,
Eskimos >> Blacks
HM– Short axial length,
Shallow AC
Iris – lens diaphragm
placed anteriorly
Plateau Iris config.
Narrow angle of AC
Small eyeball Large lens
Smaller D of cornea
Bigger size of CB
Anterior insertion of iris on
CB

5. PATHOGENESIS
Pupillary block mechanism (70%)
Phacomorphic mechanism (20%)
Plateau Iris configuration (10%)

6. PUPILLARY BLOCK
MECHANISM
Precipitating factors :
1. Physiological mydriasis – Reading in dim light,
watching tv in dark room, sympathetic overactivity
in anxiety/emotional stress.
2. Pharmacological mydriasis
• Mydriatics : Phenylephrine, Tropicamide,
Cyclopentolate, Homatropine, Atropine
• Tranquilizers
• Bronchodilators
• Anti-depressants
• Vasoconstrictors
3 Pharmacological miosis – Echothiophate, Pilocarpine

7. Mechanism :
Mydriasis  mild dilatation of pupil  Inc apposition
b/w iris and lens  Relative Pupillary Block (RPB)
Aq. Collects in PC pushes iris anteriorly Iris
Bombe  contact of iris with cornea  Appositional
angle closure  Inc IOP  formation of peripheral ant.
Synechiae  Synechial angle closure

8. Miosis  contract ciliary muscles  Zonules relax 
lens moves forward  contact of iris with lens

9. PLATEAU IRIS
• Also c/d Angle closure Glaucoma without
pupillary block.
• Insertion of iris anteriorly on ciliary body or
displacement of ciliary body anteriorly 
apposition of peripheral iris with TM  Plateau
iris configuration  iridotomy  if still acute
ACG occurs spontaneously/after pharmacological
dilation  Plateau iris syndrome  Miotics +
laser peripheral iridoplasty

11. CLASSIFICATION
Clinical (Based on symptoms)
• Latent primary ACG
• Subacute/Intermittent PACG
• Acute PACG
• Chronic PACG
Association of International Glaucoma Societies
(AIGS) – (Based on signs) :
• Primary angle closure suspects (PACS) – Latent
PACG
• Primary angle closure (PAC) – Subacute +
Acute
• Primary angle closure Glaucoma (PACG) -

12. PACS
• Symptoms – Absent
• Presenting situations – Glaucoma Screening
Programme
Routine ocular
exam
Fellow eye in pt of
acute PAC
• Signs:
1. Eclipse
sign

13. 2. Slit lamp biomicroscopy – Dec axial AC depth
- Convex shaped iris-
lens diaphragm
- Close proximity of
iris to cornea in
periphery
3. Von- Herick Slit-lamp grading of angle

14. Diagnostic criteria
• Gonioscopy – iridotrabecular contact without PAS
• IOP – normal
• OD – No glaucomatous change
• VF – Normal
ANGLE IS AT RISK.

15. PACPresents in form of:
1. Asymptomatic/Quiescent PAC  PACG
2. Subacute PAC
3. Acute PAC
Diagnostic criteria:
• Gonioscopy – Irido-trabecular contact
• IOP elevated and/or PAS +
• OD – normal
• VF – normal
ANGLE IS ABNORMAL EITHER IN FUNCTION (IF
INC IOP) OR IN STRUCTURE (IF PAS)

16. SUBACUTE PAC
• PPt factors  Attack of transient rise in IOP
(45-55 mm HG) – lasts for a few mins to 1-2
hours.
Symptoms
• Episode – unilateral transient blurring of vision
Coloured halos around light
Headache, browache, eyeache on
affected side
• Bright light/sleep  physiological miosis  self
termination of attack
• Recurrent attacks – no symptoms b/w attacks

17. ACUTE PAC
• Ppt factors  pupillary block  sudden closure of
angle  attack of rise in IOP  does not
terminate on it’s own  sight threatening
Symptoms
• Sudden severe pain
• Nausea, vomiting
• Rapidly progressive impairment of vision
• Redness
• Photophobia
• Lacrimation

18. Signs
• Lids – oedematous
• Conjunctiva – chemosed,
congested
• Cornea – oedematous,
insensitive
• AC – shallow
• Angle of AC – completely
closed on gonioscopy
• Iris – discoloured
• Pupil – semidilated,
vertically oval, fixed,
non reactive to
light/accomodation
• IOP – inc – b/w 40-70
mmHg
• OD – oedematous,
hyperaemic
• Fellow eye – Shallow AC,
occludable angle

19. PACG• PAC  untreated  gradual synechial closure of
angle of AC  PACG
Diagnostic criteria:
• Inc IOP
• PAS +
• OD – glaucomatous cupping
• VFD – similar to POAG
• Gonioscopy – iridotrabecular contact
ANGLE IS ABNORMAL IN FUNCTION AND
STRUCTURE