Angle closure-glaucoma-1259716832-phpapp01
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Transcript of Angle closure-glaucoma-1259716832-phpapp01
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Angle Closure Glaucoma
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CLASSIFICATION
Angle-Closure Glaucoma
Primary
Acute (AACG)
Chronic (CACG)
Secondary
Neovascular/ Inflammatory/ Iridocorneal endothelial
(ICE) syndrome
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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
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PREDISPOSING FACTORS
Anatomical
• Relative anterior position of iris-lens diaphragm• Shallow anterior chamber• Narrow entrance to angle
Physiological
• Physiological pupillary block
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PHYSIOLOGICAL PUPILLARY BLOCK1. 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
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SYMPTOMS1. 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
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SIGNS1. 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
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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
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Severe edematous cornea, Dilated,
unreactive,vertically oval pupil
Ciliary injection, Shallow anterior
chamber
Complete angle closure
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DIFFERENTIAL DIAGNOSIS
Usually blurred
Markedly blurred
Slightly blurred
No effect on vision
Vision
Moderate to severe
SevereModeratevariablePain
Watery or purulent
NoneNoneModerate to copious (mucopurulent)
Discharge
CommonUncommonCommonExtremely common
Incidence
Corneal trauma or infection
Acute congestive glaucoma
Acute iridocycliti
s
Acute conjunctiv
itis
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Organisms found only in corneal ulcers due to infection
No organismsNo organismsCausative organisms
Smear
NormalElevatedNormalNormalIntraocular pressure
NormalNonePoorNormalPupillary light response
NormalSemidilated and fixed
SmallNormal Pupil size
Change in clarity related to cause
HazyUsually clearClearCornea
DiffuseDiffuseMainly circumcorneal
Diffuse, more toward fornices
Conjunctival injection
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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-blockers3. Topical steriods four times daily to lower the intraocular
pressure and decongest the eye
Emergency treatment is required – preserve the sight!
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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
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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
2. Peripheral Iridectomy
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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
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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
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THANK YOU