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 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!!!