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A - MSRA Ophthalmology [14] > [8] Angle Closure Glaucoma > Flashcards

[8] Angle Closure Glaucoma Flashcards

1
Q

What is angle closure glaucoma?

A

A group of disease where there is closure of the anterior chamber angle leading to elevated intra-ocular pressure (IOP)

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2
Q

How can the closure of the anterior chamber angle be classified?

A
  • Reversible (appostional)

- Adhesional (synechial)

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3
Q

What forms can angle closure glaucoma present as?

A
  • Latent
  • Subacute
  • Acute
  • Chronic
  • Absolute
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4
Q

What is latent angle closure glaucoma?

A

Where there is anatomical predisposition to angle closure glaucoma

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5
Q

What is subacute angle closure glaucoma?

A

Mild symptomatic episodes suggestive of incomplete closure that spontaneously resolve

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6
Q

What is acute angle closure glaucoma?

A

An emergency

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7
Q

What is chronic angle closure glaucoma?

A

Insidious, progressive closing of the trabecular meshwork resulting in gradual rise in IOP

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8
Q

What is absolute angle closure glaucoma?

A

End stage of the untreated disease with irreversible and severe sight impairment

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9
Q

What is required in acute angle closure glaucoma?

A

Prompt diagnosis and treatment to save sight

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10
Q

Where is aqueous humour produced?

A

The ciliary body

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11
Q

Where is the ciliary body situated?

A

Behind the iris

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12
Q

How does the aqueous humour move from the posterior chamber of the anterior segment to the anterior chamber?

A

Via the pupil

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13
Q

How does the aqueous humour drain from the anterior chamber?

A

Through the trabecular meshwork into the canal of Schlemm which lies around the circumference of the angle between the iris and the cornea

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14
Q

What is the angle between the iris and the cornea called?

A

Anterior chamber angle (Iridocorneal angle)

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15
Q

What happens if the iris becomes opposed to the trabecular meshwork?

A

It can block off the aqueous drainage

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16
Q

What can blockage of the aqueous humour drainage cause?

A

Raise in IOP

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17
Q

How can acute angle closure glaucoma be divided?

A
  • Primary

- Secondary

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18
Q

What is primary acute angle closure glaucoma?

A

When the blockage arises as a consequence of the anatomy of the eye where the iris is pushed from behind and blocks the angle

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19
Q

In what way can the anatomy of the eye lead to acute angle closure glaucoma?

A

When some people’s angles are naturally narrowed making them vulnerable to closure

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20
Q

What is secondary acute angle closure glaucoma?

A

When there is angle closure due to forces exerted on the iris from other causes

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21
Q

What can cause primary acute angle closure glaucoma?

A

Pupillary dilation with topical mydriatics, and some systemic drugs that dilate the eye e.g. alpha-adrenergic agonists

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22
Q

Why can topical mydriatics and alpha-adrenergic agonists cause primary acute angle closure glaucoma?

A

They can push the iris into the angle and cause angle closure in people with narrow angles

23
Q

What can cause secondary acute angle closure glaucoma?

A
  • Anterior forces on the iris
  • Posterior forces on the iris
  • Blockage of the trabecular meshwork
24
Q

What anterior forces on the iris can cause secondary acute angle closure glaucoma?

A

Peripheral anterior synechiae pulling the iris up

25
Q

What posterior forces on the iris can cause secondary acute angle closure glaucoma?

A

Lens bulging forward asa result of swelling

26
Q

What can block the trabecular meshwork and cause secondary acute angle closure glaucoma?

A
  • Blood e.g. from hyphaemia
  • Blood vessels e.g. poorly controlled diabetes
  • Proteins e.g. hypertensive uveitis
27
Q

What are the risk factors for acute angle closure glaucoma?

A
  • Female
  • Family history
  • Advanced age
  • Asian or Inuit ethnicity
  • Anatomical abnormalities
28
Q

What anatomical abnormalities can increase the risk of acute angle closure glaucoma?

A
  • Thick iris
  • Thick lens
  • Shorter axial length of the eyeball front to back
29
Q

What does acute angle closure glaucoma present with?

A
  • Pain
  • Blurred vision
  • Rapidly progressing visual loss
  • Coloured halos around lights
  • Systemic malaise
  • Nausea and vomiting
30
Q

Describe the pain in acute angle closure glaucoma

A

Severe, rapidly progressing pain that can be confined to the eye but more commonly around the orbit with a frontal headache

31
Q

What is seen on examination in acute angle closure glaucoma?

A
  • Generally unwell
  • Red eye, especially around the periphery of the cornea
  • Hazy cornea
  • Non-reactive or minimally reactive mid-dilated pupil
  • Hard globe on palpation
  • Raised IOP (>21mmHg)
32
Q

What is the diagnostic criteria for acute angle closure glaucoma?

A

At least 2 of:

  • Ocular pain
  • Nausea/vomiting
  • History of intermittent blurring with haloes and at least 3 other associated signs
33
Q

3 of what associated signs must be present to diagnose acute angle closure glaucoma?

A
  • IOP >21mmHg
  • Conjunctival injection
  • Corneal epithelial oedema
  • Mid-dilated non-reactive pupil
  • Shallow chamber in the presence of occlusion
34
Q

What should investigation of acute angle closure glaucoma include?

A
  • Goinoscopy
  • Slit lamp examination
  • Visual field assessment
35
Q

What is goinoscopy used for in acute angle closure glaucoma?

A

Diagnosing angle closure (trabecular meshwork will not be visible)

36
Q

What will slit lamp examination show in acute angle closure glaucoma?

A
  • Shallow anterior chamber
  • Large optic cup
  • Narrowing of the neuroretinal rim
  • Splinter haemorrhages
  • Nerve fibre loss
37
Q

What are the differentials for acute angle closure glaucoma divided into?

A
  • Other causes of acutely raised IOP
  • Other causes of acute severe ocular pain with visual loss
  • Other causes of red eye
38
Q

What are the other causes of acutely raised IOP?

A
  • Traumatic glaucoma

- Pigmentary gluacoma

39
Q

What are the other causes of acute, severe ocular pain with loss of vision?

A
  • Corneal disorder
  • Anterior uveitis
  • Scleritis
  • Endophthalmitis
  • Optic neuritis
40
Q

What are the other causes of a red eye (other than acute angle closure glaucoma)?

A
  • Conjunctival causes e.g. keratoconjunctivitis
  • Corneal causes e.g. keratitis
  • Other causes e.g. trauma
41
Q

When is treatment for acute angle closure glaucoma required?

42
Q

What does initial medical management of acute angle closure glaucoma involve?

A

Use of all available (and not contra-indicated) topical agents with IV acetazolamide

43
Q

What topical agents are available for acute angle closure glaucoma?

A
  • Beta-blockers
  • Steroids
  • Pilocarpine
44
Q

Give an example of a topical beta-blocker used in acute angle closure glaucoma?

45
Q

Give an example of a topical steroid used in acute angle closure glaucoma?

A

Prednisolone

46
Q

What strength of pilocarpine should be used in acute angle closure glaucoma?

A
  • 1-2% in natural lens

- 2.5% without own lens

47
Q

How should acetazolamide given in acute angle closure glaucoma?

A

IV 500mg over 10 mins then 250mg slow release tablet after 1 hour

48
Q

What supportive therapy should be given to patients with acute angle closure glaucoma?

A
  • Analgesia
  • Antiemetics
  • Lay supine
49
Q

What surgical options are available for acute angle closure glaucoma?

A
  • Peripheral iridotomy
  • Surgical iridetomy
  • Lensectomy
50
Q

What is a peripheral iridotomy?

A

2 holes made in each iris with a laser to allow flow of aqueous - performed on both eyes

51
Q

When should a peripheral iridotomy be performed in acute angle closure glaucoma?

A

Within a week of acute angle closure glaucoma attack once oedema has cleared

52
Q

When is a lensectomy performed in acute angle closure glaucoma?

A

When cataractous lens has swollen to cause acute angle closure glaucoma

53
Q

What is the treatment of chronic angle closure glaucoma?

A

Peripheral iridotomy in both eyes and possibly drugs used for open angle glaucoma

54
Q

What are the potential complications of acute angle closure glaucoma?

A
  • Loss of vision
  • Repetition of acute attack
  • Attack in the other eye
  • Central retinal artery or vein occlusion

A - MSRA Ophthalmology [14] (16 decks)

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