angle closure glaucoma
DESCRIPTION
The anatomy of the anterior chamber and the diagnosis as well as treatment of ACGTRANSCRIPT
![Page 1: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/1.jpg)
ANGLE CLOSURE GLAUCOMA
Ea Raksmey
First Year Resident
2014
![Page 2: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/2.jpg)
Outline Anatomy IOP and Aqueous Humor Dynamics Pathophysiology Definition of Glaucoma Classification Diagnosis Medical Management Surgical Management
![Page 3: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/3.jpg)
Anatomy
Ciliary Body:6-7 mm wideHas 2 parts:
○ Pars plana: Avascular, smooth pigmented4 mm wideFrom ora serrata to ciliary process
○ Pars plicata:Vascularized Has around 70 radial folds (ciliary process) Zonular fibers attachment
![Page 4: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/4.jpg)
Anatomy Lined by 2 layers of epithelial cells
○ Nonpigmented Epithelium (NPE)○ Pigmented Epithelium (PE)
The apices of NPE and PE are fused together by a system of junctions and cellular interdigitations (Blood Aqueous Barrier)
![Page 5: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/5.jpg)
Anatomy
![Page 6: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/6.jpg)
Anatomy
Anterior ChamberBetween Cornea (front) and Iris (back)AC Angle lies at the corner of Cornea-Iris
junction, consists of: ○ Schwalbe Line○ Schlemm Canal and TM○ Scleral Spur○ Ciliary Process○ Iris
![Page 7: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/7.jpg)
Anatomy
![Page 8: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/8.jpg)
Anatomy
Schwalbe’s LineIs the anatomical line found on the interior
surface of the cornea, and delineates the outer limit of corneal endothelium layer.
It represents the termination of Descemet’s membrane
![Page 9: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/9.jpg)
Anatomy
Trabecular MeshworkIs a circular spongework of connective
tissue lined by trabeculocytes, that have contractile properties and may influence outflow resistance
3 portions: ○ Uveal Portion○ Corneoscleral Meshwork○ Juxtacanalicular Tissue
![Page 10: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/10.jpg)
Anatomy
![Page 11: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/11.jpg)
Anatomy
Schlemm CanalCircular tube resembling a lymphatic vesselContribute to the pressure-dependent
outflow of aqueous
![Page 12: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/12.jpg)
IOP and Aqueous Dynamics Aqueous Humor
Clear fluid that fills the PC and ACSecreted by ciliary epithelium (NPE) Flow rate 2-3 µL/mnFunctions:
○ Provide nutrients to avascular zones○ Remove metabolic wastes○ Maintain IOP○ Clear medium for transmission of light
![Page 13: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/13.jpg)
IOP and Aqueous Dynamics
![Page 14: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/14.jpg)
IOP and Aqueous Dynamics AH secretion into the PC result from:
Active Secretion: Na/K ATPase pump
Ultrafiltration: Hydrostatic/Oncotic pressure
Simple Diffusion: Different concentration
![Page 15: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/15.jpg)
IOP and Aqueous Dynamics Outflow: 0,22-0,30µL/mn/mmHg
Pressure-dependant: ○ Trabecular-Schlemm canal pathway○ 80-95 % of outflow
Pressure-independent:○ Non-trabecular or uveal pathway○ 8-15 % of outflow
![Page 16: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/16.jpg)
IOP and Aqueous Dynamics Composition of AH
Inorganic Ions:○ Na+, K+, Mg○ Ca+ ○ Cl-, HCO3-○ Iron, copper, zinc
Organic Ions: ○ Lactate and Ascorbic Acid
CarbohydratesGlutathione and UreaProteinsEnzymes
![Page 17: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/17.jpg)
IOP and Aqueous Dynamics IOP: 11-21mmHg Balance between the aqueous inflow
and outflow Fluctuation:
Higher in morning, lower in noon and evening
Heart rateBlood pressureRespiration
![Page 18: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/18.jpg)
Pathophysiology
Angle ClosureRefers to the occlusion of the TM by the
peripheral iris (Iridotrabecular Contact or ITC) Obstructing the aqueous outflow
Can be divided into two types:○ Primary ○ Secondary
![Page 19: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/19.jpg)
Pathophysiology
Primary Angle Closure GlaucomaRisk Factors:
○ Race: Blacks 20-40 times higher than whites○ Gender: Women are more likely to have
PACG than men due to shallower AC○ Age: 55-65 years old○ Refraction: Hyperopic○ Inheritance: genetics
![Page 20: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/20.jpg)
Pathophysiology
Secondary Angle Closure Glaucomacaused by impairment of aqueous outflow
secondary to apposition between the peripheral iris and the trabeculum
2 mechanisms:○ “Pushing” of Iris from behind
Pupillary block, plateau iris syndrome, malignant glaucoma, dislocated lens
○ “Pulling” of Iris forward Iris incarceration after trauma, migration of corneal
endothelium, epithelium downgrowth
![Page 21: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/21.jpg)
Definition
Glaucoma is a group of diseases characterized by:Optic neuropathy with CDR >0,5Visual field lossColor vision defect+/- elevated IOP
![Page 22: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/22.jpg)
Classification
Angle Closure GlaucomaPrimary Angle Closure Glaucoma
○ Acute Angle Closure○ Subacute Angle Closure○ Chronic Angle Closure
Secondary Angle Closure Glaucoma:○ With Pupillary Block○ Without Pupillary Block
![Page 23: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/23.jpg)
Diagnosis
Primary Angle Closure GlaucomaAcute Angle Closure
○ Definition: IOP rises rapidly as a result of relatively sudden blockage of the TM by the iris
○ Symptoms:Ocular painHeadache Blurred visionRainbow-colored halos around lightsNauseaVomitting
![Page 24: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/24.jpg)
Diagnosis○ Signs:
VA 6/60-HMHigh IOPCongested episcleral and conjuctival blood vesselsCorneal edemaShallow AC (aqueous flares and cells)Iris bombéMid-dilated, sluggish and irregularly shaped pupilGlaukomflecken
![Page 25: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/25.jpg)
DiagnosisSubacute 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
![Page 26: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/26.jpg)
DiagnosisChronic 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 symptomsModest IOP elevation Optic nerve damage Characteristic VF loss
![Page 27: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/27.jpg)
Diagnosis
Clinical Evaluation: History Ocular ExaminationGonioscopyOptic NerveVisual Field Test
![Page 28: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/28.jpg)
Diagnosis
Ocular ExaminationComplete ocular examinationAC:
○ Van Herick method:
![Page 29: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/29.jpg)
Diagnosis Gonioscopy
![Page 30: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/30.jpg)
DiagnosisShaffer System: angle between TM and iris
○ Grade 4:35-45 degreesWide open angle Visible up to iris roots
○ Grade 3: 25-35 degreesVisible up to scleral spurs
○ Grade 2:20 degreesVisible up to TM
○ Grade 1:10 degreesVisible up to Schwalbe line
○ Grade 0:Angle completely closed
![Page 31: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/31.jpg)
Diagnosis
Focal ischemic disc Myopic disc with glaucoma Senile sclerotic disc Concentrically enlarging discs
![Page 32: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/32.jpg)
Diagnosis
Baring of circumlinear blood vessels Bayoneting Collaterals Loss of nasal NRR Lamina dot sign Disc hemorrhage Sharpened edge
![Page 33: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/33.jpg)
Diagnosis
Visual Field TestEarliest stepParacentralNasal step Arcuate-shapedEnlargement Deepening Ring scotoma End stage
![Page 34: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/34.jpg)
Diagnosis
Secondary Angle Closure Glaucoma With Pupillary Block: Lens-Induced
○ Phacomorphic Glaucoma:
![Page 35: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/35.jpg)
Diagnosis
Secondary Angle Closure Glaucoma With Pupillary Block: Lens-Induced
○ Ectopia Lentis
![Page 36: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/36.jpg)
Diagnosis
Secondary Angle Closure Glaucoma Without Pupillary Block:
○ Neovascular Glaucoma○ Iridocorneal Endothelial Syndrome ○ Tumours ○ Inflammation ○ Malignant glaucoma (aqueous misdirection)
![Page 37: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/37.jpg)
Treatment
Goal of treatment:Preserve visual function Lowering IOP Prevent VF lossNeuroprotection
![Page 38: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/38.jpg)
Treatment
Medical management Decrease aqueous production:
○ Beta blockers○ Alpha agonist○ Carbonic anhydrase inhibitor
Increase uveoscleral outflow:○ PG analogs
Increase TM outflow:○ Parasympathomimetic
Induce intravascular osmolarity:○ Hyperosmotic agents
![Page 39: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/39.jpg)
Treatment
![Page 40: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/40.jpg)
Treatment
Surgical treatment Trabeculectomy Artificial filtering shunt
Laser: ○ Argon laser trabeculoplasty○ YAG laser iridotomy ○ Laser iridoplasty
![Page 41: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/41.jpg)
FIN
![Page 42: Angle Closure Glaucoma](https://reader035.vdocuments.us/reader035/viewer/2022062319/554afae8b4c9059f798b516a/html5/thumbnails/42.jpg)
References Section 2, Fundamentals and Principles of Ophthalmology.
(2010-2011). Singapore, the American Association of Ophthalmology
Section 10, Glaucoma. (2010-2011). Singapore, the American Association of Ophthalmology
Kenski, J. Jack. MD, (2011). Clinical Ophthalmology: A Systemic Approach, 7th Edition. Elsevier Saunders, UK.
Yanoff, M. and Duker, J. (2008). Yanoff & Duker: Ophthalmology, 3rd Edition. Elsevier Saunders, UK.
Ehlers, Justis, P.; Shah, Chirag, P. (2008). Will’s Eye Manual, The Office and Emergency Room Diagnosis and Treatment of Eye Diseases, 5th Edition. Lippincott Williams & Wilkins