Primary Angle Closure Glaucoma

An overview

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 7 th 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

6. 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

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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

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

23. THANK YOU!!!