week 2: Angle closure

Question 1

T/F: the iris rests on the lens?

Answer 1

False, there is about a 5 um space bw them

Question 2

what is relative pupillary block?

Answer 2

flow of aqueous from the posterior chamber through the pupil is impeded (blockage in path bw iris and lens) and obstruction creates a pressure gradient between the posterior and anterior chambers, causing the peripheral iris to bow forward against the trabecular meshwork

Question 3

Risk factors for relative pupillary block? (or just angle closure?)

Answer 3

1) older age:60-70
2) women (have shallower ACs)-except for african americans
3) fam hx
4) hyperopic eyes
5) small cornea and winter (low light)

Question 4

avg adult eye chamber depth:

Answer 4

3. 15 mm

* at risk for closure if 2.0 mm or less

Question 5

T/F: pupillary block can frequently happen not immediately after dilation but later when drops are wearing off and the pupil is mid dilation

Answer 5

true

Question 6

4 categories of angle closure:

Answer 6

1) primary angle closure suspect
2) primary angle closure
3) primary angle closure glaucoma
4) acute angle crisis glaucoma

Question 7

what classifies someone as primary angle closure suspect:

Answer 7

180 degrees or more of iridotrabecular contact on gonio in primary gaze (IOP is normal, optic nerve normal, no PAS)

Question 8

what classifies someone as primary angle closure vs just a suspect:

Answer 8

180 degrees or more of iridotrabecular contact on gonio in primary gaze but there is harm being done to eye normal nerves and field but PAS and or elevated IOP

Question 9

what classifies someone as primary angle closure glaucoma vs just a PAC:

Answer 9

180 degrees or more of iridotrabecular contact on gonio in primary gaze but there is harm being done to eye: glaucomatous fields and nerves

Question 10

outcome so far of ZAP study:

Answer 10

LPI done in one eye is effective but only for about 6 months (but still better than no LPI in fellow eye)

Question 11

in acute angle closure glaucoma, pupils will be:

Answer 11

mid dilated

Question 12

describe the AC depth, angle depth and bilaterality of Pupil Block

Answer 12

narrow angle, shallow axial depth, bilateral, iris bombe (bows)

Question 13

describe the AC depth, angle depth and bilaterality of plateau iris:

Answer 13

narrow angle, depth relatively normal, bilateral, plateau appearance on gonio

Question 14

describe the AC depth, angle depth and bilaterality of malignant

Answer 14

flat chamber, narrow angle, unilateral

Question 15

which laser do you use for LPI?

Answer 15

YAG works better for light eyes, but most docs just do both (argon then YAG)

Question 16

what 3 gtts do you give pre LPI?

Answer 16

proparacaine
pilo
apraclonidine or brimonidine (to avoid IOP spike after)

Question 17

what gtt do you give after LPI?

Answer 17

pred forte 4X a day for several days (+glaucoma meds if they need or take them)

Question 18

what is glaukomflecken?

Answer 18

infarction of ant lens epithelium from high IOP

Question 19

name 3 examples in the eye that indicate previous angle closure attacks:

Answer 19

1) peripheral ant synechiae
2) glaukomflecken
3) iris atrophy

Question 20

what is subacute angle closure glaucoma?

Answer 20

older classification: subacute/intermittent
Recurrent attacks- small
Dim lighting leads to pupil dilation and block
-PAS, particularly superiorly
-IOP often normal in office but angle very narrow

Question 21

what kind of questions should you ask someone you suspect has subacute angle closure?

Answer 21

Blurred vision, halos around lights, eye pain, HA, eye redness

Question 22

most common type of primary angle closure?

Answer 22

chronic

Question 23

what symptoms do you get with chronic primary angle closure?

Answer 23

asymptomatic

Question 24

2 types of plateau iris:

Answer 24

1) plateau iris configuration

2) plateau iris syndrome

Question 25

T/F: having an LPI makes you more prone to cataract?

Answer 25

true: After LPI about 1/3 of patients develop a cataract

Question 26

plateau iris configuration:

Answer 26

anteriorly displaced peripheral iris compromising the angle (anatomic) DESPITE deep AC

Question 27

plateau iris syndrome:

Answer 27

development of angle closure either spontaneously or after dilation in patent LPI

Question 28

iris bombe:

Answer 28

apposition of the iris to the lens or anterior vitreous, preventing aqueous from flowing from the posterior to the anterior chamber

Question 29

plateau iris more common in:

Answer 29

women

Question 30

how do you treat someone with plateau iris?

Answer 30

only tx if high IOP, maybe miotics (at night), gonioplasty

Question 31

what is gonioplasty?

Answer 31

• used to constrict the peripheral iris pulling it away from the angle
• go to the stroma and NOT all the way through
• small holes in iris near limbus

Question 32

complications of gonioplasty/iridoplasty?

Answer 32

o Corneal burns
o Marked anterior chamber inflammation
o Corneal endothelial cell damage

Question 33

what is happening in malignant glaucoma?

Answer 33

lens, ciliary body, iris all move forward

• ciliary-lenticular blockage causing the CB to move toward the lens causing aqueous to become trapped in vitreous increasing vitreous volume
• choroidal swelling

Question 34

Name some associated causes of malignant glaucoma

Answer 34

CB swelling (scleritis), CRVO, S/P PRP, Sulfa drugs, cataract surgery
-Tobramax/Topiramate- medicine used that can cause bilateral malignant glaucoma

Question 35

how to tx malignant glaucoma

Answer 35

atropine, steroids, aqueous suppressors
d/c meds that caused it
maybe try LPI

Question 36

list a few causes of NVI

Answer 36

CRVO
ocular ischemia
diabteic ret (prolif)

Question 37

tx of NVI

Answer 37

PRP and anti VEGF