Primary angle closure glaucoma is caused by blockage of the aqueous humor outflow due to closure or narrowing of the anterior chamber angle. It progresses through stages from primary angle closure suspect to acute angle closure to angle closure glaucoma, where glaucomatous optic nerve damage and visual field defects are present. Risk factors include hyperopia, smaller anterior chamber angle, older age, and Asian ethnicity. Treatment begins with intravenous mannitol or glycerol to lower pressure urgently, followed by topical eye drop medications like beta-blockers or pilocarpine. The definitive treatment is laser iridotomy or trabeculectomy surgery to permanently open the drainage angle.

1. PRIMARY ANGLE CLOSURE
GLAUCOMA
SARAL LAMICHHANE
MBBS IV Year/Roll-61

2. Introduction
Glaucoma refers to a group of disorders
characterized by progressive optic neuropathy
resulting to characteristic visual field defects;
raised Intraocular Pressure(IOP) being the most
important risk factor.
 Normal Tension Glaucoma(NTG/LTG) also exist
 Normal IOP = 10 – 21 mmHg
(Mean: 162.5 mmHg)

3. Classification:
1) Congenital & Developmental Glaucoma
2) Primary Adult Glaucoma:
(No obvious systemic/ocular cause of rise in IOP)
a) Primary Open Angle Glaucoma (POAG)
b) Primary Angle Closure Glaucoma (PACG)
c) Primary Mixed Mechanism Glaucoma
3) Secondary Glaucoma:
(Rise of IOP with some primary ocular or systemic disease)

4. Primary Angle Closure Glaucoma
Primary glaucoma in which rise in Intraocular
Pressure (IOP) occurs due to blockage of aqueous
humor outflow by closure or narrower angle of
the anterior chamber.
Predisposing Risk Factors:
1) Anatomic Factors:
- Hyperopic eye
- Iris-lens diaphragm placed anteriorly
- Narrow angle of anterior chamber
- Plateau Iris Configuration

5. 2) General Factors:
- Age: 5th Decade onwards
- Sex: Females > Males
- Rainy Season
- Family History
- Race (Caucasians, South East Asians)
- Heredity: Family history
Precipitating factors:
- Dim illumination
- Emotional Stress
- Use of mydriatics: Atropine, Tropicamide, Cyclopentolate

8. • Aqueous humor secretion from Non-pigmented
epithelium of Ciliary processes Posterior Chamber
Pupil Anterior Chamber:
• Conventional (Trabecular) Pathway: 90%
Trabecular Meshwork Canal of Schlemm
Collector Channels Episcleral Vessels
• Uveoscleral Pathway:
Trabecular Meshwork Ciliary body
Suprachoroidal space Venous Drainage

9. Mechanism:
 Relative Pupil Block
- Iris bombe formation
- Appositional Angle Closure
- Synechial angle closure
Plateau Iris Configuration
- Anteriorly positioned ciliary
displacing the iris anteriorly
Phacomorphic mechanism
- Abnormal lens

10. Symptoms:
• Eye redness
• Eyeache
• Headache
• Nausea/Vomiting
• Blurring of vision
• Colored halos
Signs:
• Circumcorneal congestion
• Corneal edema, hazy cornea
• Very shallow anterior chamber
(Eclipse Sign)
• Iridocorneal angle closure as
seen in gonioscopy
• Raised Intraocular pressure
• Reduced visual acuity
• Vertically oval & mid-dilated
pupil

11. Progression
 Primary Angle Closure Suspect:
• No clinical signs/symptoms
• Irido-trabecular contact in greater than 2700
• Intraocular Pressure (IOP) Normal
• No Peripheral Anterior Synechiae (PAS)
• Optic disc & Visual Field Normal

12. Angle Closure:
• Irido-trabecular contact in greater than 2700
• Mild clinical symptoms/signs
• IOP may or may not be raised
• PAS may or may not be present
• Optic disc & Visual Field Normal

13. Acute Angle Closure:
• Typical clinical symptoms/signs present
• Irido-trabecular contact greater than 2700
• IOP raised
• PAS present
• Optic disc & Visual field normal

14. Angle Closure Glaucoma:
• Typical clinical symptoms/signs present
• Irido-trabecular contact greater than 2700
• IOP raised, PAS formed
• Optic Nerve shows glaucomatous damage
• Characteristic visual field defect

15. Optic Nerve Changes
• Glaucomatous cupping:
Increase in Cup : Disc ratio  0.6
Normal CDR = 0.3-0.4
• Cup Asymmetry:
CDR difference > 0.2 in two eyes
• Neuroretinal rim thinning: Cup to Disc distance
ISNT Rule- Thickness of Inferior rim> Superior rim
> Nasal rim> Temporal rim
Thinning usually in same sequence

19. • Bayonetting Sign:
Z shaped bending of vessels at the margin
• Disc hemorrhages: flame shaped
• Lamellar dot sign: pores in lamina cribrosa slit
shaped & visible upto disc margin
• Peripapillary chorioretinal atrophy

22. Visual Field Defect
• Isopter contraction
• Baring of blind spot
• Paracentral Scotoma
• Siedel’s Scotoma
• Superior Arcuate or Bjerrum’s Scotoma
• Inferior Arcuate or Bjerrum’s Scotoma
• Ring or Double Arcuate Scotoma
• Roenne’s central nasal step
• Tubular Vision

26. Diagnosis
• History: Symptoms
• Clinical Examination: Signs
• Diagnostic tests:
–Tonometry: IOP measurement
–Gonioscopy: Angle structures
–Slit lamp biomicroscopy
–Ultrasonic biomicroscopy
–Fundoscopy
–Visual Field Analysis

27. Management
Principle:
Immediate medical therapy (Lower IOP)
Definitive treatment
Prophylaxis of fellow eye
Long term glaucoma surveillance and IOP
management of both eyes

28. Immediate medical therapy:
• Intravenous line access
• Systemic hyperosmotic agents:
Mannitol 20% iv 1g/kg within 30-45 mins
Glycerol oral 1g/kg of 50% solution in lemon juice
• Systemic Carbonic Anhydrase Inhibitors:
Acetazolamide 500mg oral stat followed by 250 mg tds
• Analgesics/Antiemetics

29. • Topical Antiglaucoma medication:
Beta- Blockers:
Timolol 0.5%, Betaxolol 0.5%, Levobunalol 0.5%
Prostaglandin analogue:
Latanoprost (0.005%), Bimatoprost
Alpha-1 Adrenergic agonist:
Brimonidine (0.1-0.2%)
Pilocarpine 2% qid after 1 hour
• Steroid eye drops: Anti inflammatory

30. Definitive treatment:
Peripheral iridotomy
LASER Iridotomy
Trabeculectomy (Filtration Surgery)
Fellow Eye Prophylaxis:
Pilocarpine eye drops 1drop QID
Prophylactic LASER Iridotomy

33. Take home message…..
 Glaucoma as a disease affecting optic nerve,
Raised IOP as a risk factor only.
 Pupillary block mechanism of PACG.
4 stages of progression: PACS, AC, AAC, PACG.
Optic Nerve Damage & Visual Field Defects must
be present in PACG.
Immediate therapy with Mannitol and Topical
Antiglaucoma: B-blockers, PG Analog, Pilocarpine
Definitive treatment- Iridotomy, Trabeculectomy

34. Thank You!!!!