Angle Closure Glaucoma

Angle Closure Glaucoma
Current Concepts
Dr Sanjay Shrivastava
Professor of Ophthalmology
Regional Institute of Ophthalmology
Gandhi Medical College, Bhopal
September 24,2006 Dr Sanjay Shrivastava 1

Definition
• Angle Closure Glaucomas are
characterized by apposition of peripheral
iris against trabecular meshwork, resulting
in obstruction of aqueous outflow.

• Primary Angle Closure Glaucoma term is
used when mechanism of angle closure
glaucoma is not felt to be associated with
other ocular or systemic abnormalities or
because the mechanisms are not well
understood. In this condition pupillary
block glaucoma, plateau iris and
combined mechanism glaucoma have
been included.
• Secondary Angle Closure Glaucoma is
associated with ocular or systemic
abnormalities or due to apparent
mechanism such as membrane
contraction or space occupying lesions
pushing iris forward to close angle.

Epidemiology
• Glaucoma is second leading cause of blindness
world wide. It has been estimated that by 2010
there will be 60.5 million glaucoma affected
people with approximately 26% with angle
closure glaucoma.
• Angle closure glaucoma is less common than
chronic open angle glaucoma.
• Angle closure glaucoma is common among
Asians and Eskimos but uncommon among
Africans and Caucasians

Epidemiology
• The precise ratio between the two has not
been established. Reported figures from
some of the western countries indicates
incidence of angle closure glaucoma as
0.5% in general population and 2-3 % in
>40 years age group.
• Prevalence of 1.58% has been reported in
rural south Indian population by Lingam &
co-workers (2006)

Epidemiology
• West Bengal study has reported glaucoma
in 2.63% cases in 1594 individuals >50
years examined.
• Another study has estimated that ½ of 67
million people diagnosed with glaucoma
has primary angle closure glaucoma.
According to this study 6.7 million people
globally are irreversibly blind due
glaucoma.

Stages of Glaucoma
1. Initiating events
2. Structural alterations
3. Functional alterations
4. Optic nerve damage
5. Visual loss

Stages of Glaucoma
Stages representing:
* The series of events, leading to
* Tissue changes, leading to
* Physiologic changes, leading to
* Axonal loss, leading to
* Visual field loss (progressive)

Stages of Glaucoma
* Stage I – Initiating events may be genetic or
acquired
* Stage II- Tissue changes are associated with
aqueous outflow system with vascular and
structural alteration in optic nerve head.
* Stage III- Physiologic changes are associated
with elevated IOT, reduced vascular perfusion,
laminar deformity

Stages of Glaucoma
* Stage IV – Axonal Loss leads to
*Stage V - Glaucomatous optic
neuropathy that is associated with
Glaucomatous field loss

Classification of the Glaucomas
Based on Initial events
A. Open Angle Glaucomas
B. Angle Closure Glaucomas
1. Pupillary Block Glaucoma
2. Plateau Iris Syndrome
3. Combined mechanism Glaucomas
C. Developmental Glaucomas
D. Glaucomas Associated with other
ocular and systemic disorders
Pupillary Block Glaucoma
• Also called primary angle closure
Glaucomas
– Acute
– Sub-acute
– Chronic angle closure
• Creeping angle closure
• Combined mechanism glaucoma

Classification of the Glaucomas based
on mechanism of outflow obstruction
I. Open Angle Glaucoma mechanism

II. Angle Closure Glaucoma Mechanism
III. Developmental Anomalies of the
Anterior Chamber Angle

Mechanism
A. Anterior (Pulling Mechanism)
1. Contracture of Membranes
(Neovascular Glaucoma, ICE Syndrome,
Post polymorphous dystrophy, Ocular
Trauma)
2. Contracture of Inflammatory
precipitates

Mechanism… Contd.
B. Posterior (Pushing Mechanism)
1. With Pupillary block : Pupillary Block
Glaucoma- Lens Induced Mechanism
(Intumescent lens, subluxation of lens,
mobile lens syndrome), Post synechiae
(Iris-vitreous block, pseudophakia, Uvietis)

Mechanism… Contd.
2. Without Pupillary block- Plateau iris
syndrome, malignant glaucoma, forward
vitreous shift, scleral buckling, following
PRP, CRVO, Intra ocular tumours , cysts
of iris & ciliary body, ROP, PHPV

Pupillary Block Glaucoma
Is characterized by functional block
between pupillary border of iris and ant
lens surface, usually associated with mid
dilated pupil. This leads to build up of
aqueous pressure in posterior chamber
leading to forward shift of the peripheral
iris and a closed anterior chamber.

Theories of mechanism of angle
closure glaucoma
• Relative Pupillary Block: Increased
resistance to aqueous flow from posterior
to anterior chamber between iris and lens ,
the musculature of iris exert a backward
pressure against the lens that increases
the resistance to flow of aqueous into AC
resulting in increase in pressure in PC
causes forward bulge in peripheral iris.

Stages of Angle Closure
1. Iridocorneal contact
2. Iridotrabecular contact

Anatomical Risk Factors for
Pupillary Block
• Shallow AC, Thick anteriorly placed lens ,
smaller diameter of cornea, shorter
posterior curvature of cornea, shorter axial
length , relative anterior insertion of iris,
narrow angle of AC and loose zonular
ligaments.

Pupillary Dilatation
• Mid dilated pupil of 3.5 to 6 mm is critical
limit of dilatation to cause acute attack
• Pupillary block force of dilator and
sphincter muscle and stretching force of
iris are greatest on iris in mid dilated
position (of 3.5 to 4.5 mm size)

Mechanism of Chronic Angle
Closure Glaucoma
• Peripheral Anterior Synechiae (PAS) may
develop with prolonged or recurrent acute
or subacute attack leading to chronic
angle closure glaucoma
• PAS in acute angle closure are broad
based and are seen in superior quadrant
and correlate with duration of acute attack

Mechanism of Chronic Angle
Closure Glaucoma
• Synechial closure is referred to as
shortening of the angle – creeping angle
closure. This condition can be prevented
by timely peripheral iridotomy.

Irido- corneal Contact
Ten major factors may combine to produce
irido-corneal contact:
Static factors
1. Curvature of Cornea
2. Curvature of Anterior lens surface
3. Modulus of elasticity of iris stroma

Irido- corneal Contact… Contd
Factors that can develop an acute change
4. The sphincter muscle force
5. The dilator muscle force
6. The force that results from iris stromal
strech E
7. Anterior Chamber depth

Irido- corneal Contact… Contd
Subsidiary factors
8. Aqueous inflow
9. Facility of out flow
10 Pigment release

Occludable Angle
• Occludable angle is the eye in which the
pigmented trabecular meshwork is not
visible without indentation in atleast 3 out
of 4 quadrants. The drainage angle in
such eyes is generally grade II or less i.e.
less than 20 degrees. No other
gonioscopic abnormality is present

Occludable Angle
• Some reports have concluded that
considering definition of occludable angle
for epidemiological studies will lead to
misclassification of many subject with
PACG as POAG as the current definition
of occludable angle is too stringent.
According to these authors history, clinical
examination and static and dynamic
gonioscopy remains the diagnostic gold
standard. (Foster P.J. et al 2003).
Types of Angle Closure Glaucoma
(Based on symptoms and Clinical Findings)
2. Acute angle closure glaucoma
3. Sub-acute angle closure glaucoma (also
called intermittent/ prodromal or sub-
clinical glaucoma). Sub-acute glaucoma
may lead to acute angle closure
glaucoma or chronic angle closure
glaucoma
Types of Angle Closure Glaucoma
3.Chronic Angle Closure Glaucoma
4. Combined Mechanism Glaucoma

Plateau Iris
Plateau Iris Configuration and Plateau
Iris Syndrome
• The definitions of these entities are
included here because they are primary
conditions that are often difficult to
distinguish from the PAC entities resulting
from pupillary block.

Plateau Iris
Plateau iris configuration is characterized by a
near-normal-depth central anterior chamber, a
flat iris profile, and crowding of the anterior-
chamber angle by the iris base. The IOP may be
normal or elevated. The condition appears to be
related to a forward displacement of the ciliary
processes that causes anterior displacement of
the peripheral iris and angle closure. Such
closure occurs without a significant pupillary
block component.

Plateau Iris
• Plateau iris syndrome is defined as having a
plateau iris configuration with a closed anterior-
chamber angle and usually with elevated IOP,
which persists despite the elimination of any
pupillary block component by a patent iridotomy.
Intraocular pressure elevation that was present
before iridotomy may persist; the IOP typically
increases after pupil dilation, which causes
greater occlusion of the angle by the peripheral
iris.

Combined Mechanism
Glaucomas
• Combined mechanism glaucomas refers
to condition in which both, open angle and
angle closure components are present
• After successful treatment of angle closure
glaucoma with iridotomy , eliminating all
appositional closure the IOP still remains
elevated. PAS may or may not be present

Combined Mechanism
Glaucomas
• An eye with open angle glaucoma may
develop angle closure due to natural
development of pupillary block or result
from miotic therapy

Mechanism of Combined
Glaucoma
I. Open angle glaucoma complicated by
angle closure
• Co-incidental occurrence
• Miotic induced
• Swelling of lens
• Flat AC after intraocular surgery
• PAS after ALT, PAS following
inflammation
Glaucoma
II Primary angle closure with trabecular
damage (due to acute, sub-acute or
chronic angle closure)
III Secondary open angle glaucoma with
superimposed secondary angle closure
glaucoma (post traumatic , idiopathic,
uveitic glaucoma is complicated by PAS
due to recurrence of inflammation)

Glaucoma
IV Primary open angle glaucoma with
superimposed secondary open angle
glaucoma (Secondary to trauma or
inflammation)
V. Elevated episcleral venous pressure
casing impaired outflow facility (Thyroid
Ophthalmopathy, Carotico cavernous
fistula, Struge Weber Syndrome)

Diagnostic Situations
• During the course of ocular examination,
on the basis of suspicious findings
• Patient may present with symptoms and
signs suggestive of angle closure
glaucoma.

Risk Factors
I. General Features of Patients
a. Age: Bimodal peak, at ages 53 – 58
years and at 63-70 years
b. Race: Less common amongst black
c. Sex: significant predominance of
females
d. Refractive Error: More common in
hypermetropes
Risk Factors
e. Family History: generally believed to be
inherited
f. Systemic disorders: type II Diabetes is
associated with decreased anterior
chamber depth

Precipitating Factors
I Factors that produce mydriasis
a. Dim illumination
b. Emotional stress
c. Drugs (Mydriatics – anticholinergics
including Botulinum toxin and
adrenergics

Precipitating Factors
II Factors that produce miosis, strong
cholinesterase inhibitor miotics like di-
isopropyl fluorophosphate and
ecothiophate iodide
III Sulpha based compound that produce

transient myopia due to lens swelling and
forward movement of lens iris diaphragm
Clinical Features
OCULAR FINDINGS
a. Intraocular tension (IOT) – tonometry,
tonography
b. Evaluation of peripheral anterior
chamber
* Penlight examination
* Slit lamp examination for peripheral
anterior chamber depth
Clinical Features .. contd
Slit Lamp examination (ven Herick’s
method)
Grade IV or larger – PAC > or equal to
1CT
Grade III – PAC = ¼ - ½ CT
Grade II – PAC = ¼ CT
Grade I – PAC < ¼ CT

Clinical Features … contd
Slit Lamp examination (van Herick’s
method)
Peripheral anterior chamber depth of < ¼
is considered dangerously narrow anterior
chamber angle
* Gonioscopy is indicated particularly
when peripheral AC depth is shallow,
Static and dynamic (indentation)
The Grading System for Van
Herick’s Technique
Classification - Gonioscopic Appearance
Wide open - All structures visible
Grade I narrow - Difficult to see over iris root into
recess
Grade II narrow - Ciliary body band obscured
Grade III narrow - Posterior trabeculum obscured
Grade IV narrow (closed) - Only Schwalbe’s line
visible

Gonioscopic Interpretation
• Sheie proposed system based on extent
of visualization of anterior chamber angle
structures.
• Shaffer suggested grading on the basis of
angular width of angle recess
• Spaeth suggested evaluation of angular
width of angle recess, configuration of
peripheral iris and apparent insertion of iris
root.
Newer Techniques
• Ultrasound Biomicroscopy
• Radioimaging
• OCT
• Optic nerve head (ONH) and retinal nerve
fiber layer (RNFL) assessments

ONH and layer RNFL
assessments
Qualitative
o Slit lamp biomicroscopy examination using
non-contact lenses (eg, 90-D lens) or
contact lenses (eg, central lens in
Goldmann 3-mirror lens). Green filter may
aid in the identification of RNFL thinning.
o Fundus photography for documentation
(stereoscopic or nonstereoscopic)
ONH and layer RNFL
assessments
Quantitative
o GDx VCC nerve fiber analyzer
o Heidelberg retinal tomography (HRT)
o Optical coherence tomography (OCT)

Shaffer’s Gonioscopic Classification of the
• Grade Angular Width Clinical Interpretation

• A Wide open (20° to 45° Closure
improbable
• B Moderately narrow
(10° to 20°) Closure possible
• C Extremely narrow Closure possible
• D Partially/totally closed
Closure present

Spaeth’s Gonioscopic Classification of the
Site of iris insertion

Anterior to trabecular meshwork, Schwalbe's
line
Behind Schwalbe's line, trabecular
meshwork
Scleral spur
Deep angle recess, anterior ciliary body
band
Extremely deep, posterior ciliary body band
Peripheral iris configuration
• b = bowed
• f = flat
• p = plateau
• c = concave
• Degree of iris bowing (IB): 0 to 4+

Provocative tests
1. Mydraitic Provocative test: topical
Tropicamide 1% rise of IOT of 8 mm of
Hg or more is considered positive test.
2. Dark Room Provocative test: Exposure
to dark for 60 – 90 min – rise of 8 mm of
Hg or more is considered positive test.
3. Prone Provocative test : Prone position
for 60 min , rise of 8 mm of Hg or more is
considered positive test
Provocative tests … contd
4. Pilocarpine/Phenylephrine Provocative
Test: 2% Pilocarpine and 10%
Phenylephrine are instilled simultaneously
every minute for 3 applications to achieve
mid dilated pupil – rise of 8 mm of Hg or
more is considered positive test.If negative
repeat the test . If negative after 90 min,
test is terminated by 0.5% Thymoxamine
(alpha adrenergic agonist)
Value of Provocative Tests
Questionable
Accurate history and meticulous physical
examination provides the best guide.

Symptoms of Angle Closure
Glaucoma
• Sub-acute angle closure Glaucoma – dull
ache, slight blurring
• Acute angle closure Glaucoma – Pain,
redness, blurred vision
• Chronic angle closure glaucoma –
Asymptomatic or visual field defects

Signs
1. External Ocular Examination
2. Slit lamp examination
3. Gonioscopy including compressive
gonioscopy to differentiate appositional
angle closure from synechial closure
4. Fundus examination (Hyperaemic and
edematous disc. CRVO may occur
during acute angle closure glaucoma
Signs
5. Visual fields shows non-specific
constriction. It may be constriction of
upper field or nerve fibre bundle defect.

Differential Diagnosis of acute
angle closure Glaucoma
1. Neovascular Glaucoma
2. Inflammatory causes (Post synechiae ,
iris bombe)
3. Iridocorneal endothelial Syndrome (ICE)
4. Ciliary body engorgement or
suprachoroidal effusion caused by
systemic drugs like Topiramate,
Sulphonamide and Phenothiazine
5. Ciliary body engorgement associated with
retinal vein occlusion or PRP
6. Ciliary body block syndrome
7. After incisional or LASER PI
8. Phacomorphic lens induced glaucoma

9. Developmental anomalies like
nanophthalmos, ROP, PHPV
10. Iris or ciliary body mass lesion
11. Open angle glaucoma.

Management

Management Goals
• Identification of patients at risk of
developing primary angle closure (PAC)
glaucoma or to identify patients with PAC
• To manage an acute attack
• To prevent permanent damage to angle of
anterior chamber
• To ensure that patient leads a symptom
free life
Management Goals
• To determine other mechanism of angle
closure glaucoma than pupillary block
• To reverse or prevent angle closure by
LASER PI or incisional iridectomy
• To determine residual angle closure after
iridotomy
• To observe for chronic IOP elevation,
progression of synechial angle closure /
optic nerve damage and treat as indicated
MEDICAL THERAPY
Approaches
e. To reduce IOP
f. To relieve the angle closure

a. Reduction of IOP
• ORAL THERAPY
1. Acetazolamide
2. Glycerol
3. Isosorbid
• INTRAVENOUS THERAPY
1. Mannitol
2. Acetazolamide

a. Reduction of IOP
TOPICAL THERAPY
2. Beta-adrenergic blockers
3. Alpha 2 Adrenergic Agonist
4. Topical carbonic anhydrase inhibitor
5. Topical miotic

b. Relief of Angle Closure
1. Pilocarpine 1 or 2 %
2. Topical thymoxamine 0.5% (Eserine and
Echothiopate Iodide are not indicated)
3. LASER PI
4. If not possible then surgical / incisional
iridectomy
5. Lensectomy

Prophylactic Iridotomy
• Previously normal IOP is elevated
• A potentially occludable angle is present
• PAS that are attributable to episodes of angle
closure are present
• There is progressive narrowing of the angle
• Medication is required that may provoke
pupillary block
• Symptoms are present that suggest prior angle
closure
Prophylactic Iridotomy
• The patient's occupation/avocation makes
it difficult to access immediate ophthalmic
care (e.g., the patient travels frequently to
developing parts of the world or works on
a merchant vessel).
• For the fellow eye in patients who have
had an attack of acute PAC (as described
in the section about “acute primary angle
closure” under Orientation).

Follow-up Protocol
• Follow up to evaluate
a. Patency of Iridotomy
b. IOP measurement
c. Gonioscopy
d. Pupillary dilatation to decrease risk of
posterior synechiae
f. Fundus examination

Follow up Protocol
• Patient should be examined to evaluate
history and ocular examination at one
week to 4 months if target IOP has been
achieved but if damage is progressive
every 3 months to every 12 months if
target IOP has been achieved and no
progressive damage.

Follow up Protocol
• If target IOP has not been achieved then
patient should be followed up frequently
• Optic Disc should be evaluated after every
2 –12 months interval and visual field
should be checked every 1 to 6 months
depending on achieving target IOP

Counseling
• Patient at risk may be warned about taking
decongestants, motion sickness
medication and Anticholinergic agents.
Patients should be informed about
symptoms of acute angle closure
glaucoma and to consult Ophthalmologist
immediately if symptoms occur.

Angle Closure Glaucoma - Current Concepts

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I. Open Angle Glaucoma mechanism

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III Sulpha based compound that produce

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• Grade Angular Width Clinical Interpretation

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Site of iris insertion

• Degree of iris bowing (IB): 0 to 4+

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