primary angle closure glaucoma.dr ferdous
TRANSCRIPT
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Dr Md Ferdous Islam
Dept of Ophthalmolgy CMH,Dhaka
PRIMARY ANGLE CLOSURE GLAUCOMA
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Angle Closure
Occlusion of the Trabecular Meshwork by the peripheral iris(iridotrabecular contact-ITC) obstructing the aqueous outflow
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Stages In Natural History1 Primary angle-closure suspect (PACS) • Gonioscopy shows posterior meshwork ITC in
three or more quadrants but no PAS • Normal IOP, optic disc and visual field
2 Primary angle-closure (PAC) • Gonioscopy shows three or more quadrants of ITC
with raised IOP and/or PAS, or excessive pigment smudging on the TM • Normal optic disc and field
3 Primary angle-closure glaucoma (PACG) • Gonioscopy shows ITC in three or more quadrants
• Optic neuropathy
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Risk Factors
• Positive family history for angle closure• Age : relative pupillary block 60 yrs or over. Younger
for non pupillary block• Women• History of Angle closure symptoms• Hypermetropia• Axial length• Racial group Indian Asians & Far Eastern
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MechanismRelative Pupillary Block • Failure of aqueous flow through the mid dilated
pupil leads to a pressure differential between the anterior and posterior chambers, with resultant anterior bowing of the lax iris [Iris bombe] blocks trabecular meshwork and iridolenticular contact
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Non-pupillary block • Specific anatomical factors include plateau iris
(anteriorly positioned ciliary processes), and a thicker or more anteriorly-positioned iris
• Plateau iris configuration is characterized by a flat central iris plane in association with normal central anterior chamber depth. The angle recess is very narrow, with a sharp iris angulation over anteriorly positioned and/or orientated ciliary processes
• Plateau iris syndrome describes the occurrence of angle-closure despite a patent iridotomy in a patient with morphological plateau iris
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• Lens induced angle closure
• Retrolenticular
• Combined mechanism
• Reduced aqueous outflow
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Shaffer grading
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Ocular Manifestations• Symptoms Decreased vision Halos around lights Frontal headache Ocular pain Nausea and vomiting Precipitating factors Watching TV in a dark room Pharmacological Mydriasis Sympathetic agonist (Inhalers)
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Signs
APAC 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
Subacute Angle Closure
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Resolved APAC
• 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
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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
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Sequence Of Events• Acute angle closure sudden ,circumferential , iridotrabecular
apposition-rapid severe rise in IOP• Intermittent angle closure Self limiting episodes of ITC ,milder signs &
symptoms of former• Creeping angle closure slowly progressive ITC –Elevated IOP• Chronic angle closure irreversible , iridotrabecular
adhesion ,asymptomatic unless significant raised IOP
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Investigations1. Anterior segment OCT2. Anterior chamber depth measurement3. Posterior segment USG4. Provocative tests Pharmacological test pupillary block mechanism in mid dilated state ,increased
tension of iris . Performed with short acting mydriatic [phenylephrine eye
drops] if test proves positive –acute attack may be triggered
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Dark room prone test pupil dilates in dark,lens moves forwards in prone. - Patient sits for 30 minutes in dark with head
prone ,no sleeping - IOP checked rapidly ,positive if increases by 8 mm
Hg
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Treatment
APACInitial Treatment1.Supine Position2. IV Acetazolamide 500mg if IOP >50mm of Hg. oral if <50mm
of Hg3.Additional oral dose of 500 mg of Acetazolamide4.Apraclonidine 0.5%-1%,timolol 0.5%,prednisolone 1%5.Pilocarpine 2-4% 1drop ½ hourly repeatedly,1% 1 drop to the
fellow eye6. Analgesic and antipyretic
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Resistant case1.Central corneal indentation2.Further pilocarpine, timolol, apraclonidine, prednisolone3.Mannitol 20% IV 1-2gm/kg over 1 hr, oral glycerol 50%
1gm/kg or oral isosorbide 1gm/kg4.Paracentesis5.Clearing cornel oedeme with glycerol6.Surgical :PI, Laser iridotomy, iridoplasty, lens extraction,
goniosynechialysis,trabeculectomy
Subsequent Med Treatment1.Pilocarpine 2% 4 times to affected eye,1% 4 times to
fellow eye2.Topical steroid 4 times3.(Any of ) timolol or apraclonidine or oral acetazolamide
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PACS1.Laser iridotomy2. If ITC persists –laser iridoplasty, long term pilocarpine
prophylaxis, lens extraction
PAC & PACG1.As for PACS but urgency & intensity of treatment with
frequent review with anti glaucoma medications and neuroprotective drugs.
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Peripheral Laser Iridotomy• A hole is made in iris periphery allowing aqueous to drain
from PC into TM• Helps eliminate high aqueous pressure behind iris and iris
falls back.• Done using Nd:YAG laser ,150-200 microns size 3-6 mj of
power based on thickness• Topical pilocarpine 30 mins before laser therapy, identify
crypt in iris and create opening• Post op steroids and antiglaucoma meds
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Surgical Peripheral Iridectomy
• Removal of iris tissue by knife or scissors• 2-3 mm peripheral corneal incision in
superotemporal site• Alternatively ,conjunctival peritomy and scleral
limbus incision wound closure• Externalised iris piece held with toothed forceps ,
incised with fine scissors
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