Angle-closure glaucoma is characterized by a closed anterior chamber angle that obstructs aqueous humor drainage from the eye, increasing intraocular pressure. It can be acute or chronic. Acute angle-closure glaucoma causes a rapid rise in pressure leading to pain, blurred vision, nausea, and elevated eye pressure. Treatment involves medications to lower pressure and laser or surgery to reopen the angle to restore drainage. Without treatment, permanently high pressure can damage the optic nerve and cause vision loss from glaucoma.

1. Angle Closure
Glaucoma

2. CLASSIFICATION
Angle-Closure Glaucoma
Primary
Acute (AACG) Chronic (CACG)
Secondary
Neovascular/
Inflammatory/
Iridocorneal
endothelial (ICE)
syndrome

3. DEFINITION
• Closed-angle glaucomas are characterized by a
shallow anterior chamber that forces the root of
the mid-dilated iris forward against the trabecular
network, obstructing the drainage of aqueous
humor and thereby increasing the intraocular
pressure.
Groups at Risks
1. Age >60 years
2. Gender: females > males (4:1)
3. Race: Asians
4. Family history: increased risk with 1st degree relatives

7. PREDISPOSING FACTORS
• Relative anterior position of iris-lens
diaphragm
• Shallow anterior chamber
• Narrow entrance to angle
Anatomical
• Physiological pupillary block
Physiological

8. 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

9. SYMPTOMS
1. Rapidly progressive impairment 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

10. SIGNS
1. Reduced visual acuity
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

12. ACUTE CONGESTIVE ANGLE CLOSURE
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

13. Severe
edematous
cornea, Dilated,
unreactive,
vertically oval
pupil
Ciliary injection,
Shallow
anterior
chamber
Complete angle
closure

14. DIFFERENTIAL DIAGNOSIS
Usually
blurred
Markedly
blurred
Slightly
blurred
No effect on
vision
Vision
Moderate to
severe
Severe
Moderate
variable
Pain
Watery or
purulent
None
None
Moderate to
copious
(mucopurulent
)
Discharge
Common
Uncommon
Common
Extremely
common
Incidence
Corneal
trauma or
infection
Acute
congestive
glaucoma
Acute
iridocyclitis
Acute
conjunctivitis

15. Organisms
found only in
corneal ulcers
due to
infection
No organisms
No organisms
Causative
organisms
Smear
Normal
Elevated
Normal
Normal
Intraocular
pressure
Normal
None
Poor
Normal
Pupillary light
response
Normal
Semidilated
and fixed
Small
Normal
Pupil size
Change in
clarity related
to cause
Hazy
Usually clear
Clear
Cornea
Diffuse
Diffuse
Mainly
circumcorneal
Diffuse, more
toward
fornices
Conjunctival
injection

16. MANAGEMENT
– Prevent adhesions of peripheral iris to trabecular
meshwork resulting in permanent closure of angle
1. I.V acetazolamide 500mg followed by oral
acetazolamide 250mg qid after acute attack has broken
2. Topical beta-blockers
3. Topical steriods four times daily to lower the intraocular
pressure and decongest the eye
Emergency treatment is
required – preserve the sight!

17. Reassessment
• Evaluate IOP
• Evaluate adjunct drops
• May need osmotic agents? Immediate
iridotomy?
Approx 1 hr
after initial RX
• Start with Pilocarpine (myotic drug)
every 15mins x 2 doses

18. SURGICAL MANAGEMENT
1. Peripheral laser iridotomy (LPI)
(YAG Laser)
– To establish the communication between the posterior and anterior
chambers by making an opening in the peripheral iris
– This will be successful only if less than 50% of the angle is closed by
permanent peripheral anterior synechiae
1. Peripheral Iridectomy

19. 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

20. 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