Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016

Corso AISG-SIGLA
Glaucoma da Chiusura d’Angolo
Template a cura di Giorgio Marchini

In ambito medico, la semeiotica (dal greco σημεῖον, semèion, che significa
"segno", e dal suffisso -iké, "relativo a") sintomi
segni
L'etimologia del termine è identica a quella di semiotica ma, per
consuetudine, la parola "semeiotica" viene utilizzata solo per definire quella
medicina sintomi
malattia
diagnosi
In senso lato,
(radiologia, elettrocardiografia, endoscopia, ecc).
σημεῖον, semèion

laucoma rimario da hiusura d’ ngolo
(angolo potenzialmente «occludibile», Occhio a rischio di GPCA)
- da «blocco posteriore» (es. gl. maligno)
- da «trazione anteriore» (es. gl. neovascolare)

N.B. GPCA cronicizzato = attacco acuto non risolto

• Test di Van Herick
• 5 classi (gradi da 4 a 0)
• Screening per occhi a rischio di chiusura
• Non sostituisce la gonioscopia

• Angoli non pericolosi: grado 4 e grado 3
• Attenzione al grado 2
• Angoli pericolosi: grado 1 e grado 0
N.B. Grado 2: gonioscopia dinamica!

- raggio di curvatura più corto
- necessità di mezzo accoppiante
- raggio di curvatura più lungo
- appoggiata direttamente

Strutture angolari
• Schwalbe
• Trabecolato anteriore e posteriore
• Sperone sclerale
• Banda ciliare

26
Gonioscopia
Disegno L.Allen

 Meccanismo di chiusura
- blocco pupillare
- senza blocco pupillare
 Chiusura apposizionale o anatomica
 Ruolo del cristallino

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

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

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

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

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

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

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
iridocyclitis
Acute
conjunctivitis

Organisms
found only in
corneal ulcers
due to
infection
No organismsNo organismsCausative
organisms
Smear
NormalElevatedNormalNormalIntraocular
pressure
NormalNonePoorNormalPupillary light
response
NormalSemidilated
and fixed
SmallNormalPupil size
Change in
clarity related
to cause
HazyUsually clearClearCornea
DiffuseDiffuseMainly
circumcorneal
Diffuse, more
toward
fornices
Conjunctival
injection

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

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

Ultrasound biomicroscopy
• Allows to visualize iris,iris root,CS
junction,ciliary body,lens.
• To elucidate the mechanism of angle closure

Ocular manifestations
• Symptoms:
Decreased vision
Halos around lights
frontal headache
Ocular pain
nausea and vomiting

1. Acute congestive glaucoma
Elevated IOP risen rapidly
Conjunctival congestion
Corneal epithelial /stromal edema
Shallow or flat peripheral AC
mid dilated [vertical oval] pupil
absent /sluggish pupil reaction
Fellow eye generally shows an occludable angle

2. Chronic presentation
• ‘Creeping’ angle-closure [gradual band-like anterior
advance of the apparent insertion of the iris]. From
deepest part of the angle and spreads circumferentially.
• • Episodic (intermittent) ITC is associated with the
formation of discrete PAS, individual lesions having a
pyramidal (‘saw-tooth’) appearance.
• Disc cupping /nerve fibre defects with or without visual
field defect

3 Resolved acute (post-congestive) angle
closure
• Folds in Descemet membrane (if IOP has been reduced
rapidly), optic nerve head congestion and choroidal folds.
• Later iris atrophy [spiral-like configuration], irregular pupil,
posterior synechiae and glaukomflecken
• Iris torsion

Diagnosis
• Primary Angle Closure Glaucoma
– Acute Angle Closure
• Definition: IOP rises rapidly as a result of
relatively sudden blockage of the TM by the iris
• Symptoms:
– Ocular pain
– Headache
– Blurred vision
– Rainbow-colored halos around lights
– Nausea
– Vomitting

Diagnosis
• Signs:
– VA 6/60-HM
– High IOP
– Congested episcleral and conjuctival blood vessels
– Corneal edema
– Shallow AC (aqueous flares and cells)
– Iris bombé
– Mid-dilated, sluggish and irregularly shaped pupil
– Glaukomflecken

Diagnosis
– Subacute or Intermittent Angle Closure
• Blurred visions, halo
• Mild pain by elevated IOP
• IOP is normal between episodes
• May  to chronic angle closure glaucoma or
acute attack if not resolve spontaneously

Diagnosis
– Chronic Angle Closure
• May develop after acute attack in which synechial
closure persists
• Or after AC chamber close gradually or IOP slowly rises
(Creeping Angle)
• Resembles open angle glaucoma due to:
– Lack of symptoms
– Modest IOP elevation
– Optic nerve damage
– Characteristic VF loss

Diagnosis
• Clinical Evaluation:
– History
– Ocular Examination
– Gonioscopy
– Optic Nerve
– Visual Field Test

Physical findings in acute angle-closure glaucoma with
pupillary block
3/3/2019
• Findings during an acute attack of angle-closure glaucoma
• Two of the following symptom sets:
 Periorbital or ocular pain
 Diminished vision
 Specific history of rainbow haloes with blurred vision
 IOP higher than21 mmHg
• plus three of the following findings:
 Ciliary flush
 Corneal edema
 Shallow anterior chamber
 Anterior chamber cell and flare
 Mid-dilated and sluggishly reactive pupil
 Closed angle on gonioscopy
 Diminished outflow facility
 Hyperemic and swollen optic disc
 Constricted visual field

Acute congestive angle-closure glaucoma
• Severe corneal oedema
• Complete angle closure
(Shaffer grade 0)
• Dilated, unreactive,
vertically oval pupil
• Shallow anterior
chamber
• Ciliary injection
Signs

3/3/2019
• Findings suggesting previous episodes of acute angle-
closure glaucoma
 Peripheral anterior synechiae
 Posterior synechiae to lens
 Glaukomflecken
 Sector or generalized iris
atrophy
 Optic nerve cupping and/
or pallor
 Visual field loss
 Diminished outflow facility

Differential diagnosis of acute angle-closure
glaucoma
3/3/2019
• Evidence of compromised angle on gonioscopy or
shallow anterior chamber
 Ciliary block glaucoma (aqueous misdirection or
malignant glaucoma)
 Neovascular glaucoma
 Iridocorneal endothelial syndrome
 Plateau iris syndrome with angle closure
 Secondary angle closure with pupillary block (e.g.,
posterior scleritis)
 Cilio-choroidal detachments (bilateral)

3/3/2019
• High-pressure open-angle glaucomas
masquerading as acute angle closure
Glaucomatocyclitic crisis
Herpes simplex keratouveitis
Herpes zoster uveitis
Sarcoid uveitis
Pigmentary glaucoma
Exfoliative glaucoma (may have associated
angle closure)

Canadian Ophthalmological
Society
Evidence-based Clinical Practice
Guidelines for the Management of
Glaucoma in the Adult Eye

Angle-closure glaucomas
• The most useful classification for angle-closure
glaucoma is based upon etiology.
• The most important criterion is the presence or
absence of pupil block, with further sub-
classification into primary and secondary
mechanisms.
• The prevalence of PACG varies significantly
among different ethnic groups.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.

Angle-closure glaucomas
• Patients with PACG commonly present with
1 of 3 possible scenarios:
– acute angle closure,
– narrow angle at risk of acute closure with normal
IOP, or
– creeping angle closure with or without elevated
IOP.
• Patients may present with what appears to be
chronic OAG, but angle closure is subsequently
discovered on gonioscopy.

Pupil Primary Examples of secondary
Pupil block Primary acute
or chronic
angle closure
• Posterior synechiae
• Silicone oil
• AC IOL without iridectomy
• Lens subluxation or lens swelling
Non-pupil
block
Plateau iris
syndrome
• Posterior mechanisms
− Choroidal tumour
− Choroidal effusion
o medication-induced (sulfonamides)
o spontaneous
− Ciliary block
− Lens-induced
• Anterior mechanism
− Angle neovascularization
− Iritis
− ICE syndrome
− Epithelial down growth
Classification of angle closure
based on functional cause

Risk factors for development of
primary angle closure
• Axial hyperopia
• Family history of angle closure
• Advancing age
• Female gender
• East Asian ethnicity
• Inuit ethnicity
• Latino ethnicity
• Shallow peripheral anterior chamber
• Short axial length eyes

Acute angle closure:
Signs and symptoms
Symptoms include: • Severe pain
• Headache
• Nausea and vomiting
• Blurred vision
• Halos around lights
• Conjunctival injection
Signs include: • Ciliary flush
• Corneal edema
• Fixed mid-dilated pupil
• Shallow anterior chamber
• Elevated IOP
• Sometimes glaukomflecken
• The angle is observed to be closed
on gonioscopic examination

Narrow angle at risk of closure
(angle-closure suspect)
• A patient would be considered an angle-closure
suspect if he or she had iridotrabecular contact
on gonioscopy without PAS, and without GON
and VF damage.
• There are usually no symptoms associated with
a narrow angle; however, intermittent angle
closure is possible.

Narrow angle at risk of closure
(angle-closure suspect) (cont’d)
• Signs of narrow angle at risk of closure include:
– Shallow peripheral anterior chamber and an
open angle on gonioscopy.
– Trabecular meshwork, while still visible, is
almost or partially occluded.
• The IOP is not elevated.

Creeping angle closure
• There are no symptoms associated with
creeping angle closure.
• Signs include:
– normal or elevated IOP,
– PAS in portions of the angle,
– possible optic disc damage, and
– possible glaucomatous VF defects.

Diagnosis of
Angle Closure Glaucomas

Diagnosis of
angle closure glaucoma
• Diagnosis requires a detailed history and physical exam.
• History must include:
– whether the pupil has ever been pharmacologically dilated,
– medication history to elicit the use of medications that may dilate the
pupil, such as those:
o with anticholinergic effects/side effects
o that counteract the iris sphincter muscle
o with sympathomimetic effects that work on the iris dilator muscle,
o that may cause anterior movement of the lens iris diaphragm (e.g.,
sulfonamides)
– family history of acute glaucoma or previous laser iridotomy in a
first-degree relative, and
– personal history indicative of symptoms of previous
intermittent attacks of angle closure.

Diagnosis of
• On examination, it is important to note:
– visual acuity
– refractive error
– pupil size and reaction
– presence of corneal edema
– anterior chamber depth centrally and peripherally
– presence of iris or angle new vessels indicative of
neovascularization
– presence of anterior chamber inflammation
– IOP
– lens appearance

Diagnosis of
• Gonioscopy of both eyes is mandatory to assess
the depth of the anterior chamber and the
presence of PAS (compression gonioscopy with
a Zeiss-type lens is very useful in differentiating
PAS from apposition).

Gonioscopy technique in
narrow angles
Recommendation
Careful gonioscopy, performed under ideal
conditions (dim ambient light, narrow light beam
from the slit lamp, use of compression gonioscopy)
is fundamental to assess the presence of angle
closure in patients suspected of having narrow
angles [Consensus].

Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016

Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Similar a Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016

Similar a Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016 (20)

Más de Nicola Canali

Más de Nicola Canali (20)

Último

Último (20)

Aisg sigla semeiotica glaucoma angolo stretto dott nicola canali brescia 2016