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Angle-Closure Glaucoma Flashcards

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1
Q

What percentage of bilateral blindness in China is attributed to angle closure glaucoma?

A

91%

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2
Q

What percentage of presentation is acute/abrupt? Chronic and insidious?

A

20-30% of cases present acutely

70-80% of causes are asymptotic and insidious

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3
Q

What are the two varieties of angle closure glaucoma?

A 
Primary= anatomical predisposition to angle closure
Secondary= an identifiable anatomic cause that initiates the angle closure
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4
Q

What is the hallmark physical exam finding in angle closure glaucoma?

A

apposition or adhesion of the peripheral iris to the TM (either via rear push or forward pull mechanism)

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5
Q

What is the most common cause of angle closure glaucoma?

A

Pupillary block

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6
Q

What is pupillary block? When is angle closure maximum?

A

obstruction of the lens-iris interface that causes a pressure gradient b/w the PC and AC, which in turn causes the peripheral iris to bow anteriorly

angle closure is maximized when the pupil is mid-dilated

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7
Q

What is the leading cause of glaucoma worldwide?

A

angle closure

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8
Q

What is a general characteristic of eyes that are more susceptible to angle closure?

A

Hypertropic eyes, or eyes with axial length < 20 mm, are at increased risk for PACG

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9
Q

How does most angle closure present?

A

asymptomatic chronic disease without an acute attack

usually bilateral

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10
Q

If angle closure presents unilaterally, what other causes should be considered in the differential diagnosis?

A
  • posterior segment mass
  • zonular insufficiency
  • ICE syndrome
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11
Q

What are RFs for angle closure?

A
  • shallow AC (<2.5 mm)
  • increased anterior curvature of lens
  • short axial length
  • small k diameter and radius of curvature
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12
Q

How does angle closure relate to age?

A

prevalence of angle closure increases each decade after age 40 2/2 increased thickness of lens and forward movement of iris, causing increased iridolenticular contact

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13
Q

Is there a gender prevalence for angle closure?

A

Woman are 2-4x more likely to suffer from angle closure 2/2 smaller AC and AC angle

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14
Q

If a myopic patient presents with angle closure, what should be considered as a part of the Ddx?

A
  • microspherophakia
  • plateau iris
  • phacomorphic closure
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15
Q

What are s/sx of angle closure?

A
  • increased IOP
  • blurred vision/decreased central VA
  • rainbow colored halos around lights
  • n/v
  • ocular pain
  • shallow ac
  • mild AC reaction (cell and flare)
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16
Q

How do you distinguish between appositional and synechial angle closure via physical exam?

A

Dynamic gonioscopy

If appositional, blockage will be reversible

If synechial, not reversible

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17
Q

Why do patients with angle closure present with blurred vision/visual symptoms?

A

K endothelial edema

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18
Q

What are glaucomflecken?

A

characteristic small anterior sub capsular lens opacities 2/2 ischemia

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19
Q

What is the definitive treatment of angle closure?

A

B/L LPI, or less commonly, surgical iridectomy

mild attacks may be broken with miotics (2/2 pulling peripheral iris away from TM)

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20
Q

How do mitotic agents work to decrease IOP?

A

They decrease IOP in angle closure by pulling peripheral iris away from TM

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21
Q

If an LPI cannot be performed, how can an attack of acute angle closure be broken?

A

laser iridoplasty (flattens peripheral iris) or laser pupilloplasty

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22
Q

What is subacute/intermittent angle closure?

A

characterized by episodes of blurred vision, halos, and mild pain 2/2 increased IOP

Often resolves spontaneously

sx more common at night

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23
Q

What is chronic angle closure?

A

gradual asymptomatic closure, which is the most common form

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24
Q

How is chronic angle closure managed?

A

LPI (unless significant lens opacity is present; then perform lensectomy)

if synechial angle closure: goniosynechiolysis

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25
Why do chronic angle closure and POAG need to be considered in the differential diagnosis for patients presenting with increased IOP?
They both need to be considered b/c they usually are both asymptomatic, or present with initial modest IOP increase, progressive glaucomatous ON damage, and characteristic VF loss
26
What are the indications to perform an iridotomy?
- narrow angle with appositional/near appositional angle closure - PAS - increased TM pigmentation - Hx of previous angle closure - (+) provacative test results (>8 mm Hg increase in IOP) - significant risk of angle closure (AC depth < 2mm, strong FamHx)
27
What is plateau Iris?
atypical configuration of the AC angle that may cause ACG; typically in young females usually 2/2 anteriorly positioned ciliary processes that push the iris forward
28
What is the characteristic sign of plateau iris on ultrasound?
"Double Hump" sign
29
What is the treatment for plateau iris?
LPI (to remove pupillary block) | lensectomy (if cataract present)
30
How do plateau iris configuration and plateau iris syndrome differ?
plateau iris configuration may be treated with LPI Plateau Iris Syndrome will not respond to LPI, needs to be treated with laser iridoplasty
31
What is phacomorphic glaucoma?
pathological narrowing of the angle related to acquired mass effect of cataractous lens itself generally occurs slowly with formation of the cataract
32
What is the treatment for phacomorphic glaucoma?
Laser iridotomy followed by CE (in most cases, CE is definitive treatment)
33
What is ectopia lentis? How can it cause glaucoma?
Displacement of the lens from normal anatomical position If displaced forward, pupillary block can occur, causing Iris bombe, shallow AC angle, and secondary ACG
34
What are the causes of ectopia lentis?
``` Exfoliation syndrome (most common cause) Trauma Marfans Syndrome Homocystinuria Microspherophakia Well-Marchesani Syndrome ```
35
What is the treatment for ectopic lentos?
2 LPIs 180 degrees apart followed by lensectomy
36
When is ectopia lentis an emergency?
when lens becomes displaced into the AC
37
What is microspherophakia?
a congenital disorder when lens has a spherical or globular shape, which can cause ectopia lentis with subsequent pupillary block Often familial; may be isolated, or occur as a part of a syndrome (Weil-Marchsani or Marfan)
38
What is the treatment for microspherophakia?
Cycloplegia
39
What is aphakic/pseudophakic angle closure?
due to capsular block, which is when retained viscoelastic or fluid in the capsular bag pushes the PCIOL anteriorly
40
What is the treatment for aphakic/pseudophakic angle closure?
Laser iridotomy or vitrectomy (PRN)
41
How does angle closure without pupillary block occur?
Can occur via 2 mechanisms: 1- CTX of inflammatory/hemorrhagic/vascular membrane/band or exudate in the angle causing PAS 2- forward displacement of the lens-iris interface, often accompanied by swelling and anterior rotation of the CB
42
What is neovascular glaucoma?
characterized by retinal/ocular ischemia or inflammation leading to severe secondary angle closure
43
What are the common causes of neovascular glaucoma?
- Diabetic retinopathy - CRVO - Ocular Ischemic Syndrome
44
What is the common PE finding in neovascular glaucoma?
fine arborizing blood vessels of the iris, pupillary margin, or TM; usually begins as fine vascular tufts at the pupillary margin that grow and extend radially over the iris sometimes accompanied by a fibrous membrane
45
What is a distinguishing factor of NV glaucoma v other secondary angle closure glaucomas?
the PAS in NV glaucoma end at schwalbes line (they don't grow over healthy K endothelium)
46
What percentage of patients present with NVA that do not have NVI?
10% of patients with CRVO present this way
47
What is the treatment for NV glaucoma?
In a patient with clear corneas, PRP or intravitreal Anti-VEGF In pts with cloudy cornea: Panretinal cryotherapy, IOP Rx, steroids (for inflammation) In patient with 20/400 or better: trabeculectomy with MMC or drainage tube In pts who are CF or worse: transcleral diode laser cyclophotocoagulation
48
What is iridocorneal endothelial syndrome?
a non familial group of disorders characterized by abnormal corneal endothelium with variable iris atrophy, secondary angle closure, and corneal edema unilateral
49
How does ICE syndrome present?
usually presents in females b/w 20-50 y/o with unilateral increased IOP, decreased VA, secondary angle closure glaucoma, and abnormal iris appeareance
50
What is essential iris atrophy?
a variant of ICE syndrome characterized by severe iris atrophy with heterochromia, corectopia, ectropion uveae, iris stromal and pigment epithelial atrophy/hole formation
51
What is Chandler Syndrome?
most common variant of ICE syndrome, characterized by minimal iris atrophy + corectopia + K and angle findings (predominate) makes up 50% of ICE cases
52
What is Cogan Reese Syndrome?
less severe iris atrophy + tan pedunculated nodules or diffuse pigmented lesions on the anterior iris surface
53
How often does glaucoma occur in patients with ICE syndrome?
glaucoma occurs in 50% of patients with ICE syndrome
54
In which variant of ICE syndrome is glaucoma the most severe?
is most severe in essential iris atrophy and cogan reese syndrome
55
What is the cause of glaucoma in ICE syndrome?
K endothelium migrates posterior to schwalbes line into the TM, causing PAS
56
What is the treatment for ICE Syndrome?
``` Hypertonic saline (for K edema) Aqueous suppressants or PG analogs to decrease IOP ``` Rx-> filtration surgery-> drainage devices -> cyclophotocoagulation
57
What are the most common cancerous causes of secondary angle closure glaucoma?
primary choroidal melanomas ocular metastasis Retinoblastoma
58
How do choroidal/retinal tumors lead to secondary angle closure glaucoma?
shift the iris-lens interface forward
59
How does inflammation cause secondary angle closure glaucoma?
fibrin and increased aqueous protein (2/2 breakdown of blood-aqueous barrier) can lead to formation of posterior synechiae and PAS
60
What is different about PAS in inflammatory angle closure compared to other angle closure?
PAS tend to occur mainly in the inferior angle and tend to be non-uniform in height and shape
61
What is Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?
secondary angle closure glaucoma thought to be 2/2 anterior rotation of CB and posterior misdirection of aqueous with associated relative block
62
What type of patients develop Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?
usually presents in patients s/p ocular surgery with a hx of angle closure or PAS RF: - small hyperopic eyes - CE - Cessation of cycloplegia - LPI or CPC - Drainage Tube implantation
63
How does Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome present?
usually p/w uniform flattening or central and peripheral chamber (usually markedly different compared to other eye)
64
What is a hallmark sign of Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?
optically clear "aqueous" zones in the vitreous
65
How do you treat Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?
triad of intensive cycloplegic therapy + aggressive aqueous suppression, and shrinking of vitreous with hyper osmotic agents 50% of patients can be controlled with laser iridotomy and Rx management
66
What is the definitive surgical treatment of Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?
PPV with anterior hyaloidozonulectomy
67
How do non RRD and Uveal Effusions cause secondary angle closure?
they cause forward displacement of the lens-iris interface
68
What is the treatment for angle closure glaucoma in non-RRD and uveal effusions?
Aqueous suppressants Cycloplegia Steroids
69
How do epithelial ingrowths cause secondary angle glaucoma? Where do they come from?
is a rare surgical complication when CT invades the AC via a defect in the wound site
70
What are the risk factors for epithelial ingrowth SACG?
- prolonged inflammation - wound dehiscence - delayed wound closure - Descemets membrane tear
71
How do scleral buckles lead to SACG?
they produce shallowing of the AC, often accompanied by choroidal effusion and anterior rotation of CB
72
How do scleral buckles occur after gas/oil retinopexy?
act as space occupying lesions, pushing lens-iris interface anteriorly
73
How is SACG managed when caused by retinal surgery?
Aqueous suppressants, atropine, corticosteroids | Removal of oil/gas/buckle + primary glaucoma surgery
74
What is nanophthalmos and how does it cause SACG?
an eye with axial length < 20 mm, a small K diameter, and a relatively large lens for the volume of the eye causes glaucoma 2/2 thickened sclera impeding vortex veins; eyes are also extremely hyperopic
75
What is the treatment for SACG related to nanophthalmos?
- laser iridotomy - argon laser peripheral iridoplasty - Rx therapy - avoid surgery if possible
76
How does persistent fetal vasculature cause SACG?
contracting retrolental tissue can case a progressive shallowing of AC with subsequent ACG (usually occurs from 3-6 mos old)
77
When a patient has a flat AC, what cause should be assumed first?
Wound leak
78
How does topiramate (and possibly acetazolamide) cause SACG?
causes relaxation of zonular fibers and profound displacement of lens-iris complex, causing ACG and high myopia
79
How does topiramate induced SACG present?
bilateral sudden loss of vision with acute myopia (>6D), bilateral ocular pain, and head ache usually occurs within 1 month of starting Rx
80
What are PE findings in topiramate-induced SACG?
- uniformly shallow AC with anterior iris-lens displacement - microcystic K edema - increased IOP (40-70 mm Hg) - closed AC angle - Ciliochoroidal effusion/detachment
81
What is the treatment for topiramate-induced SACG?
immediate d/c of topiramate | Aqueous suppresents +/- cycloplegia
82
How soon after discontinuation of topiramate does induced myopia resolve?
1-2 after stopping medication

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