PRIMARY ANGLE-

CLOSURE GLAUCOMA
(PACG)
EPIDEMIOLOGY

• In 2010, the worldwide estimated prevalence of angle-closure

glaucoma was 15.7 million with nearly 25% of cases resulting in
bilateral blindness.
• PACG is more commonly seen in women and certain ethnic groups
Table 1. Geographic Distribution of Primary Angle-Closure Glaucoma

Latin America and the Caribbean 1.6%

Sub-Saharan Africa 0.6%

Middle East/North Africa/South-west Asia 1.3%

China 37.1%

India 12.7%

Other Asian & Pacific countries (high income) 8.8%

Other Asian & Pacific countries (low income) 17.6%

Source: World Bank, 1994.

DIFFERENTIAL DIAGNOSIS

 Inflammatory open angle glaucoma

 Retrobulbar hemorrhage or inflammation
 Traumatic (hemolytic glaucoma)
 Glaucomatocyclitic crisis (Posner-Schlossman syndrome)
 Pigmentary glaucoma
DEFINITION

Angle closure refers to a diverse group of anatomical

disruptions of the anterior segment that lead to mechanical
blockage of the trabecular meshwork by the peripheral iris,
thereby resulting in increased IOP with subsequent optic
disc and visual field changes that together diagnostically is
referred to as angle-closure glaucoma.
PATHOPHYSIOLOGY
• Etiology of Primary Angle Closure
• Relative pupillary block (apposition of lens and posterior iris at pupil
leads to blockage of aqueous humor from anterior to posterior
chamber)
• Angle crowding secondary to plateau iris or other abnormal iris
configuration
• Etiology of Secondary Angle Closure

• Peripheral anterior synechiae (PAS) secondary to inflammation including uveitis

• Neovascular or fibrovascular membrane pulling angle closed (neovascular glaucoma, NVG)
• Membrane obstructing angle in iridocorneal endothelial syndrome (ICE) or epithelial downgrowth
• Lens-induced
• Phacomorphic (iris-trabecular contact as a result of a large lens)
• Nanophthalmos (small eye)
• Pseudoexfoliation syndrome (zonular loss/weakness)
• Miotic-induced angle closure
• Drug sensitivity (topiramate and sulfonamides, also: antidepressants, anticholinergics, allergy
and cold medications containing antihistamines) presenting with bilateral angle closure due to
supraciliary effusion and ciliary body swelling, with consequent anterior rotation of lens–iris
diaphragm
• Choroidal swelling following tight encircling scleral buckle, extensive retinal laser, retinal vein
occlusion
• Posterior segment tumor
• Hemorrhage choroidal detachment
• Aqueous misdirection syndrome/malignant glaucoma
• Uveal effusion
• Posterior scleritis
• Retrolenticular tissue contracture (ROP/PHPV)
SIGNS, SYMPTOMS

• Symptoms
• Pain (may radiate in CN V distribution with associated secondary
lacrimation)
• Blurred vision
• Colored rings around lights
• Frontal headache
• Nausea
• Vomiting
• Sweating
• Bradycardia
• Signs
• Closed angle in involved eye
• Elevated IOP (sometimes as high as 70 mmHg)
• Cornea edema (microcystic)
• Conjunctival injection
• Fixed mid-dilated pupil
• Eyelid edema
• Anterior Chamber angle Assessment:

• Van Herick technique: Peripheral temporal depth anterior chamber with slit-
lamp beam < one-fourth depth of normal corneal thickness thought to be highly
suspicious for angle closure.
• Not a substitute for gonioscopy
• Gonioscopy is the gold standard for diagnosis, indirect gonioscopy using a 4-
mirror lens. Ideal conditions include:
• Completely dark room
• Thin slit-lamp beam
• No pressure on gonio lens initially
• Visualization of the entire angle 360° before any indentation
• During indentation, corneal curvature is altered thereby aqueous is sent
peripherally into the angle recess opening an appositionally closes angle.
• Indentation gonioscopy useful in differentiating between appositional closure versus
PAS, dynamic change observed under direct visualization
• Variety of angle grading systems, most common being the Shaffer and Spaeth
systems
• If available, ultrasound biomicroscopy (UBM) is noninvasive and may assist in
diagnosis and provide detailed information about the anterior chamber, ciliary
body, zonules, iris configuration, lens, and posterior chamber
• Newer technologies to further examine the angle include anterior segment
optical coherence tomography (AS- OCT), SPAC depth analyzer, Pentacam
MANAGEMENT
• Medical Management

• Indentation gonioscopy—may break an acute attack

• Topical aqueous suppressants
• Alpha 1-agonists (brimonidine 0.1%–0.2%)
• Topical carbonic anhydrase inhibitors (dorzolamide/brinzolamide)
• Topical beta-blocker (timolol 0.5%)—used with caution in asthma/chronic obstructive pulmonary disease
• Prostaglandin analogues (latanoprost/bimatoprost/travoprost)
• Steroids (prednisolone acetate 1%)
• Miotic agents (pilocarpine)—controversial
• Topical glycerin may be used to improve view through edematous cornea for examination or laser therapy
• Oral or intravenous carbonic anhydrase inhibitor (acetazolamide 250–500 mg) — caution with renal dysfunction
• Hyperosmotic agents (mannitol/glycerol)
• Anterior chamber paracentesis:
• May provide rapid lowering of IOP, pain and corneal edema
• Caution in phakic patients and large pupils
• Corneal indentation:
• Acute angle closure possibly relieved by forcefully pressing on the cornea with a 4-mirror indirect gonioscopy lens
• Laser iridotomy
• ND:YAG, argon diode, or combination of both
• Should be strongly considered in all patients
• Eliminated pressure differential between anterior and posterior chamber
• Contraindications: neovascular glaucoma, ICE syndrome, choroidal effusion
• Peripheral iridoplasty:
• Consider in cases where laser iridotomy not possible or does not eliminate appositional angle.
• Procedure places contracting burns in extreme iris periphery to contract iris stroma and physically pull open angle.
• Surgery
• Indications similar to those for open angle glaucoma, principally
when IOP cannot be managed with medical and/or laser therapy
• Trabeculectomy
• Glaucoma drainage tube implants
• Lens extraction with or without trabeculectomy
• Surgical iridectomy—patients uncooperative or nonsuitable for standard
laser therapy
• Management Plan
1. Treat acute attack.
• Break pupil block (pilocarpine, aqueous suppressants (by opening the
angle) and indentation).
• Control IOP.
• Treat inflammation.
2. Prevent future attacks with peripheral iridotomies.
3. Detect and control ongoing glaucomatous optic neuropathy
 Table 3. Resource Availability, United Kingdom
Resource Availability
Equipment
Slit lamp A
Gonioscopy lens A
IV cannulation equipment A

• Treatment YAG laser A

Argon laser A
Iridotomy contact lens (eg, Wise or Abraham) A

Medication
Acetazolamide IV preparation A
Acetazolamide oral preparation A
Pilocarpine drops A
Timolol drops A
Apraclonidine drops A
Steroid drops (eg, prednisolone) A
Analgesic medication A
Anti-emetic medication A
Key
A Freely available locally
B Available at regional centre
C Available at national centre
D Not freely available

(Courtesy of Anthony Khawaja, MB, MA (Cantab), MRCOphth_

• Immediate
• IV acetazolamide 500 mg
• Guttae (g.) pilocarpine (eye drops) stat (2% in light irides, 4% in
dark irides—avoid intense/repeat administration)
• G. timolol 0.25% stat (if no medical contraindications)
• G. apraclonidine 0.5% stat
• G. prednisolone 1% stat
• Lie patient supine if patient’s overall condition permits
• Analgesics and antiemetics as indicated
• Reassessment after 60 minutes
• If IOP still elevated, consider:
• Indenting central cornea gently with 4 mirror gonioprism (2–3
cycles of 30 seconds on, 30 seconds off)
• Argon laser peripheral iridoplasty
• Once IOP is reduced, carry out bilateral laser peripheral iridotomies
(PI).
• After care
• If IOP is controlled, discharge on:
• G. pilocarpine 2% (4% in dark irides) qid
• G. apraclonidine 0.5% tid
• G. prednisolone 1% 2 hourly affected eye and qid fellow eye
• PO acetazolamide 250mg qid
• Review as an outpatient to assess PI patency, and full glaucoma
workup including dilated examination.
• Laser peripheral iridotomy technique
• Medication and anaesthetic:
• Pre-medication with apraclonidine 0.5% and pilocarpine (2% in blue
eyes, 4% in brown eyes), at least 30 minutes before laser
• topical anaesthetic
• Apply a Wise or Abraham iridotomy contact lens.
• Check the defocus on YAG laser is set to zero.
• Consider argon laser pre-treatment for thick brown irides.
• Use the lowest power possible by starting low and working
upwards (usually 0.8–1.5mJ).
• Aim for iris crypts between 11–1 o’clock.
• Extend iridotomies circumferentially up to 200 μm.
• Prescribe post-procedure topical steroid for at least a week.
THANK YOU