Primary angle closure glaucoma is caused by apposition of the peripheral iris against the trabecular meshwork, obstructing aqueous outflow. It is a major cause of glaucoma blindness worldwide. Risk factors include older age, female sex, Southeast Asian or Chinese descent, hyperopia, anatomically narrow anterior chamber angles, and heredity. Primary angle closure can progress to primary angle closure glaucoma if untreated, causing increased intraocular pressure and optic nerve damage. Treatment options include laser peripheral iridotomy, medications, filtration surgery, and lens extraction depending on the stage and severity of the condition.

1. PRIMARY ANGLE
CLOSURE GLAUCOMA
DR. PRAKRITI YAGNAM. K

2. Primary angle closure disease – apposition of peripheral
iris against trabecular meshwork resulting in aqueous flow
obstruction
-If optic disc changes and visual field defects present called
primary angle closure glaucoma
- Major cause of world glaucoma blindness
- For every 10 PACG suspects one case occurs
- Chronic PACG more common than acute
- India POAG:PACG is 1:1

3. RISK FACTORS:
- Age – 6 and 7th decades
- Gender – M:F is 1:3
- Race – More common in south east Asians,Chinese .
Uncommon in blacks
- Hypermetropic eyes
- Eyes with iris lens diaphragm forwardly placed
- Narrow angle
- Plateau iris configuration
- Hereditary

4. Pathogenesis :
1. Pupillary block mechanism
2.Plateau iris syndrome
3.Phacomorphic
Pupillary block :
i. Precipitating factors :
Physiological mydriasis
Pharmacological mydriasis
Pharmacological miosis
Valsalva manoevure

5. Precipitating factors
middilated pupil
relative pupil block
iris bombe formation
appositional angle closure
synechial angle closure

10. 2. Plateau iris syndrome :
- Due to anteriorly placed ciliary process pushing
peripheral iris anteriorly
- Due to pushing mechanism anterior chamber is closed
- Angle closure glaucoma without pupillary block
- Treated with miotics and laser peripheral iridotomy

12. 3. Phacomorphic :
- Abnormal lens may cause pupillary block or pushes iris
anteriorly causing closure angle glaucoma
- Treatment - lens extraction

13. Classification :ISGEO
Primary angle closure suspect
Primary angle closure
Primary angle closure glaucoma

14. Primary angle closure suspect :
- Latent primary angle closure glaucoma
- Symptoms absent
- Fellow eye may already had an attack
- Signs – Eclipse sign – pen torch method
- Slit lamp – decreased axial anterior chamber depth
- Convex shaped iris lens diaphragm
- Peripheral proximity of iris and cornea

16. Von Herick grading :
Grade 4 wide angle – ¾ to 1 CT
Grade 3 Mild narrow – ¼ to ½ CT
Grade 2 Moderate narrow – ¼ CT
Grade 1 extremely narrow - <1/4 CT
Grade 0 closed angle
Diagnosis : IOP
Gonioscopy
Ultrasonic biomicroscopy
Ant segment OCT

20. Optic disc evaluation
Visual field analysis
Diagnostic criteria :
- IOP normal
- No PAS
- Iridotrabecular contact present
- Disc and fields normal
Provocative tests : Prone darkroom or mydriatic tests

21. Treatment :
- Prophylactic laser iridotomy
- Periodic follow up
Primary angle closure : Subacute , acute , chronic
- Iridocorneal contact present with PAS
- IOP raised
- No optic disc or field changes

22. Subacute :
- Intermittent attacks present lasting for few minutes to 1-2
hours
- IOP upto 50mm Hg
- Precipitating factors present
- Symptoms : Unilateral transient blurring of vision
- Colored halos around light not broken by finchams test
- Self termination by physiological miosis
- Recurrent attacks common
Treatment : Peripheral laser iridotomy

23. Acute primary angle closure :
- Sudden closure of angle
Symptoms : Pain with nausea and vomitings
- Rapid deterioration of vision with redness and photophobia
- Past history of subacute attacks present
Signs : Lid edematous
- Conjunctiva chemosed and congestion present
- Cornea is edematous
- AC shallow with cells and flare
- Angle occluded completely

24. - Iris discolored
- Pupil midilated fixed
- IOP upto 70mm Hg
- Optic disc edema and hyperemia
- Fellow eye may also have occludable angle
DD:
- Acute red eye
- Acute secondary glaucomas

26. Management :
To lower IOP - IV Mannitol(1gm/kg bodywt.)or Oral Glycerol
IV acetazolamide 500mg.stat f/by 250 mg PO
TID
Topical antiglaucoma drugs
Pilocarpine QID after IOP lowered
Analgesics and antiemetics
Compressive gonioscopy
Topical steroids

27. Definitive :
- Laser peripheral iridotomy
- Filtration surgery – Trabeculectomy
- Clear lens extraction
- Prophylactic treatment of normal fellow eye
- Follow up
Sequelae :
- Post surgical – Normalised with PI or trabeculectomy
- Spontaneous angle reopening
- Ciliary body shutdown

30. - Due to ischemia of ciliary epithelium
- Recovery causes rise in IOP with glaucomatic changes
- Treatment : - Topical steroids
- Laser PI
- Trabeculectomy
Vogts triad :
1.Glaucomoflecken
2.Iris atrophic patches
3.Slightly dilated non reacting pupil

32. 3. Primary angle closure glaucoma :
- Gradual synechial closure of angle
- Untreated PAC may convert to PACG
- Divided into subacute,acute,chronic
- Acute and subacute similar to their counterparts in angle
closure disease along with disc and field changes
Chronic PACG – similar to POAG with closed angles
- Symptoms - eyeball white and painless
- IOP raised
- Gonioscopy reveals closed angles
- DISC and field changes present

33. Diagnostic criteria :
- Iridocorneal contact with PAS
- IOP elevated
- Disc and field changes
Treatment : Laser. PI along with medical therapy
Trabeculectomy
Prophylactic laser iridotomy

34. Absolute PACG :
- Untreated cases
- Painful blind eye – no PL
- Perilimbal reddish blue zone
- Caput medusae
- Cornea hazy goes into bullous keratopathy or filamentary
keratitis
- AC shallow
- Iris atrophic
- Pupil fixed and dilated
- IOP high and eye stony hard

36. Complications :
- Corneal ulceration
- Staphyloma formation
- Atrophic bulbi
Treatment :
- Retrobulbar alcohol injection
- Destruction of ciliary epithelium(secretory)-
cyclocryotherapy
- Enucleation

38. THANKYOU!!!