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glaucoma > Angle-Closure Glaucoma > Flashcards

Angle-Closure Glaucoma Flashcards

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
Q

Why do chronic angle closure and POAG need to be considered in the differential diagnosis for patients presenting with increased IOP?

A

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

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26
Q

What are the indications to perform an iridotomy?

A
  • 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)
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27
Q

What is plateau Iris?

A

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

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28
Q

What is the characteristic sign of plateau iris on ultrasound?

A

“Double Hump” sign

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29
Q

What is the treatment for plateau iris?

A

LPI (to remove pupillary block)

lensectomy (if cataract present)

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30
Q

How do plateau iris configuration and plateau iris syndrome differ?

A

plateau iris configuration may be treated with LPI

Plateau Iris Syndrome will not respond to LPI, needs to be treated with laser iridoplasty

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31
Q

What is phacomorphic glaucoma?

A

pathological narrowing of the angle related to acquired mass effect of cataractous lens itself

generally occurs slowly with formation of the cataract

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32
Q

What is the treatment for phacomorphic glaucoma?

A

Laser iridotomy followed by CE (in most cases, CE is definitive treatment)

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33
Q

What is ectopia lentis? How can it cause glaucoma?

A

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
Q

What are the causes of ectopia lentis?

A 
Exfoliation syndrome (most common cause)
Trauma
Marfans Syndrome
Homocystinuria
Microspherophakia
Well-Marchesani Syndrome
35
Q

What is the treatment for ectopic lentos?

A

2 LPIs 180 degrees apart followed by lensectomy

36
Q

When is ectopia lentis an emergency?

A

when lens becomes displaced into the AC

37
Q

What is microspherophakia?

A

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
Q

What is the treatment for microspherophakia?

A

Cycloplegia

39
Q

What is aphakic/pseudophakic angle closure?

A

due to capsular block, which is when retained viscoelastic or fluid in the capsular bag pushes the PCIOL anteriorly

40
Q

What is the treatment for aphakic/pseudophakic angle closure?

A

Laser iridotomy or vitrectomy (PRN)

41
Q

How does angle closure without pupillary block occur?

A

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
Q

What is neovascular glaucoma?

A

characterized by retinal/ocular ischemia or inflammation leading to severe secondary angle closure

43
Q

What are the common causes of neovascular glaucoma?

A
  • Diabetic retinopathy
  • CRVO
  • Ocular Ischemic Syndrome
44
Q

What is the common PE finding in neovascular glaucoma?

A

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
Q

What is a distinguishing factor of NV glaucoma v other secondary angle closure glaucomas?

A

the PAS in NV glaucoma end at schwalbes line (they don’t grow over healthy K endothelium)

46
Q

What percentage of patients present with NVA that do not have NVI?

A

10% of patients with CRVO present this way

47
Q

What is the treatment for NV glaucoma?

A

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
Q

What is iridocorneal endothelial syndrome?

A

a non familial group of disorders characterized by abnormal corneal endothelium with variable iris atrophy, secondary angle closure, and corneal edema

unilateral

49
Q

How does ICE syndrome present?

A

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
Q

What is essential iris atrophy?

A

a variant of ICE syndrome characterized by severe iris atrophy with heterochromia, corectopia, ectropion uveae, iris stromal and pigment epithelial atrophy/hole formation

51
Q

What is Chandler Syndrome?

A

most common variant of ICE syndrome, characterized by minimal iris atrophy + corectopia + K and angle findings (predominate)

makes up 50% of ICE cases

52
Q

What is Cogan Reese Syndrome?

A

less severe iris atrophy + tan pedunculated nodules or diffuse pigmented lesions on the anterior iris surface

53
Q

How often does glaucoma occur in patients with ICE syndrome?

A

glaucoma occurs in 50% of patients with ICE syndrome

54
Q

In which variant of ICE syndrome is glaucoma the most severe?

A

is most severe in essential iris atrophy and cogan reese syndrome

55
Q

What is the cause of glaucoma in ICE syndrome?

A

K endothelium migrates posterior to schwalbes line into the TM, causing PAS

56
Q

What is the treatment for ICE Syndrome?

A 
Hypertonic saline (for K edema)
Aqueous suppressants or PG analogs to decrease IOP

Rx-> filtration surgery-> drainage devices -> cyclophotocoagulation

57
Q

What are the most common cancerous causes of secondary angle closure glaucoma?

A

primary choroidal melanomas
ocular metastasis
Retinoblastoma

58
Q

How do choroidal/retinal tumors lead to secondary angle closure glaucoma?

A

shift the iris-lens interface forward

59
Q

How does inflammation cause secondary angle closure glaucoma?

A

fibrin and increased aqueous protein (2/2 breakdown of blood-aqueous barrier) can lead to formation of posterior synechiae and PAS

60
Q

What is different about PAS in inflammatory angle closure compared to other angle closure?

A

PAS tend to occur mainly in the inferior angle and tend to be non-uniform in height and shape

61
Q

What is Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?

A

secondary angle closure glaucoma thought to be 2/2 anterior rotation of CB and posterior misdirection of aqueous with associated relative block

62
Q

What type of patients develop Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?

A

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
Q

How does Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome present?

A

usually p/w uniform flattening or central and peripheral chamber (usually markedly different compared to other eye)

64
Q

What is a hallmark sign of Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?

A

optically clear “aqueous” zones in the vitreous

65
Q

How do you treat Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?

A

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
Q

What is the definitive surgical treatment of Aqueous Misdirection/malignant glaucoma/CB glaucoma/Posterior Aqueous Dispersion Syndrome?

A

PPV with anterior hyaloidozonulectomy

67
Q

How do non RRD and Uveal Effusions cause secondary angle closure?

A

they cause forward displacement of the lens-iris interface

68
Q

What is the treatment for angle closure glaucoma in non-RRD and uveal effusions?

A

Aqueous suppressants
Cycloplegia
Steroids

69
Q

How do epithelial ingrowths cause secondary angle glaucoma? Where do they come from?

A

is a rare surgical complication when CT invades the AC via a defect in the wound site

70
Q

What are the risk factors for epithelial ingrowth SACG?

A
  • prolonged inflammation
  • wound dehiscence
  • delayed wound closure
  • Descemets membrane tear
71
Q

How do scleral buckles lead to SACG?

A

they produce shallowing of the AC, often accompanied by choroidal effusion and anterior rotation of CB

72
Q

How do scleral buckles occur after gas/oil retinopexy?

A

act as space occupying lesions, pushing lens-iris interface anteriorly

73
Q

How is SACG managed when caused by retinal surgery?

A

Aqueous suppressants, atropine, corticosteroids

Removal of oil/gas/buckle + primary glaucoma surgery

74
Q

What is nanophthalmos and how does it cause SACG?

A

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
Q

What is the treatment for SACG related to nanophthalmos?

A
  • laser iridotomy
  • argon laser peripheral iridoplasty
  • Rx therapy
  • avoid surgery if possible
76
Q

How does persistent fetal vasculature cause SACG?

A

contracting retrolental tissue can case a progressive shallowing of AC with subsequent ACG (usually occurs from 3-6 mos old)

77
Q

When a patient has a flat AC, what cause should be assumed first?

A

Wound leak

78
Q

How does topiramate (and possibly acetazolamide) cause SACG?

A

causes relaxation of zonular fibers and profound displacement of lens-iris complex, causing ACG and high myopia

79
Q

How does topiramate induced SACG present?

A

bilateral sudden loss of vision with acute myopia (>6D), bilateral ocular pain, and head ache

usually occurs within 1 month of starting Rx

80
Q

What are PE findings in topiramate-induced SACG?

A
  • uniformly shallow AC with anterior iris-lens displacement
  • microcystic K edema
  • increased IOP (40-70 mm Hg)
  • closed AC angle
  • Ciliochoroidal effusion/detachment
81
Q

What is the treatment for topiramate-induced SACG?

A

immediate d/c of topiramate

Aqueous suppresents +/- cycloplegia

82
Q

How soon after discontinuation of topiramate does induced myopia resolve?

A

1-2 after stopping medication

glaucoma (8 decks)

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