L2 acute closed angle glaucoma

Question 1

What are the symptoms of PAC?

Answer 1

acute:
Ocular pain (severe)
– Rapidly decreasing vision (unilateral)
– Haloes around lights
-Blurred vision
– Nausea/ vomiting
– Possible abdominal pain

intermittent:
– Episodes of blurring (lasting 1-2 hours) associated with haloes, eye ache or frontal headache
– Often at night or when in dim conditions (mid-dilate

suspect/chronic:
asymptomatic- angle progressively closing over time

Question 2

What are the signs of acute angle closure

Answer 2

• High IOP (40-80mmHg)
• Red eye: limbal and conjunctival vessel dilation (ciliary flush)
• Corneal oedema (epithelial)
• Reduced VA (6/60 – HM)
• Fixed, mid-dilated, vertically oval pupil
• Shallow/ flat AC
• Posterior synechiae
• Iris bombe and PAS
• Closed angle VH
• Iridotrabecular contact of 360̊ on
  gonioscopy

Question 3

What is the differential diagnosis of acute angle closure?

Answer 3

-Acute Anterior Uveitis
- Miotic pupil
- Cells and flare in AC

• Lower/normal IOP (unless posterior synechiae present)
• Keratic precipitates

Question 4

What is the referral of PAC?

Answer 4

Question 5

What is the management of pac?

Answer 5

Immediate medical treatment to lower IOP and open angle:
– Acetazolamide (diamox)
– Pilocarpine
– Anti-inflammatory agents
– Timolol
* Peripheral Iridotomy
* Lie flat on back for first hour

Question 6

What are the late signs of acute angle closure attack?

Answer 6

Iris atrophy
* Lens glaukomflecken
* IOP returns to normal or slightly elevated level
* Risk of progressive optic neuropathy (glaucoma)
* Persistent synechial closure
* Pupil remains inactive or poorly reactive (mid-dilated)

Question 7

Key clinical examinations to investigate pac?

Answer 7

VH
GONIOSCOPY(looking for 360 degrees of contact)

Question 8

What are the causes of pupillary block/ what anatomical factors increase the risk of primary angle closure?

Answer 8

1. shallow AC= distance bw posterior surface of cornea + ant error surface of lens is reduced
2. anterior lens position= if lens is further forward angle more narrow.
3. short axial length (hyperopic) =
   small corneal diameter (distance reduced)

4 Anterior positioning of iris-ciliary body junction= if its more forward , angle more narrow

Question 9

How does pupil block cause angle closure? PATHOGENESIS

Answer 9

1. Posterior synechiae formation: post iris and ant lens are touching
   (Iris adheres to the lens )
2. :. blocks the flow of aq humor from the posterior chamber to the anterior chamber.
   Aq humor cannot be drained out through trab meshwork

3.Aq humor is trapped and builds up in the posterior chamber behind the eye. This blockage increases iop as it cannot circulate throughout the eye.

4.Causes iris bombe: iris bulges forward
Peripheral; anterior synechaie: Anterior surface of the iris makes contact with the contact poster surf cornea.

Adhesion between the anterior surface of the iris and the corneal endothelium.

5. Causing angle closure

Question 10

What is the pathogenesis of acute angle closure glaucoma?

Answer 10

A
- WITH pupil block

• Pupillary dilation leads the iris and lens contact increasing the pupillary block.
• Increasing pupillary block leads to bulging of iris, acutely closing the AC angle, thus obstructing aqueous humour outflow.
• IOP raises slightly.
• WITHOUT pupil block
• Ciliary body positioned anteriorly than normal.
• Iris naturally closer to cornea
• Thickened and convexed peripheral iris fold.

Question 11

What is the aetiology of acute angle closure glaucoma?

Answer 11

It develops as an after effect of either primary/secondary angle closure glaucoma.

Synechial/oppositional closure of the AC angle by peripheral iris.

Question 12

What are the risk factors of acute angle closure glaucoma?

Answer 12

Age,
Female Gender,(smaller eyes)
East Asian, (shallow AC)
Family Hx, (anatomical changes of eye inherited)
Hyperopia (smaller eye, everything closer together) (increases likelihood of closure

Question 13

What is the pathogenesis of acute angle closure without pupillary block?

Answer 13

iris plateau syndrome
Anteriorly positioned ciliary body
- Anterior insertion of iris root into ciliary body

-closer apposition b/w iris +cornea

space b/w where trabecular meshwork is more narrow–> iris has a flatter position–> as it has moved forward–.> more contact b/w iris and cornea

=so more likely to close angle

Question 14

What are the features of a without pupil block?

Answer 14

Normal AC depth
Thickened/convex peripheral iris roll

Question 15

how can dilation cause angle closure?

Answer 15

1. iris is pulled taught/tight
2. iris rolls backwards with dilation
3. this can block the angle= so drainage is blocked.

Question 16

What are the key features/characteristics of PACG?

Answer 16

Closed angle: irido-trabecular contact in 3 or more quadrants on gonioscopy (Van Herricks grade 0/1)
* Raised IOP
* Glaucomatous optic nerve changes
* Glaucomatous visual field defects

Question 17

What causes the pain in acute angle closure?

Answer 17

-iop is high
-nerves being activated more
-more mechanical pressure on nerves

Question 18

What causes the decreasing vision and haloes?

Answer 18

1. endothelial pump not working
2. not able to drain fluid so fluid accumulates.
3. corneal becomes oedematous due to swelling in cornea.= decrease in vision
4. light getting scattered= haloes

Question 19

What causes nausea and abdominal pain?

Answer 19

vagus nerve is effected and radiation of pain ti the abdominal area happens