Review of angle closure glaucomas, By Fritz Allen, MD
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Review of angle closure glaucomas, By Fritz Allen, MD
- 1. Review of Angle closure Glaucomas Fritz Allen MD Visionary Ophthalmology November 10th 2013
- 2. Angle-Closure Glaucomas Acute Primary Angle-Closure Glaucomas Neovascular Glaucoma 2
- 4. Gonioscopy Indications Overcomes problem of total internal reflectivity to see angle structures Indirect gonioscopy (e.g., Goldmann or four mirror lens) Essential diagnostic tool in glaucoma (viewing the iridocorneal angle) Most common cause of incorrect diagnosis is omission of gonioscopy Omission causes overlooking secondary glaucomas and other glaucomas Periodically performed can detect secondary emergence of mixed mechanism 4
- 5. Gonioscopy Identification of angle recession, foreign bodies, abnormal pigmentation, tumors, angle neovascularization, angle synechiae Glaucoma treatment in the angle Laser trabeculoplasty Goniosynechialysis Treatment and evaluation of internal ostium of trabeculectomy site Gonioplasty/iridoplasty 5
- 6. Gonioscopy Contraindications Inability of patient to cooperate Corneal abrasion or disease precluding application of corneal lens Pre-procedure evaluation Indirect gonioscopy View angle with slit-lamp using a gonioscopic lens Technique 6 Indirect gonioscopy Produces inverted image 180 away from origination Two types of lenses are in common use
- 7. Gonioscopy Goldmann type Goldmann lens requires clear fluid to fill space between cornea and goniolens Lens is brought toward patient’s eye and tipped forward quickly enough to trap the clear fluid 4 mirror type Requires only drop of anesthetic Indentation gonioscopy can be performed 7 Rests solely on cornea / tear film Technique to differentiateappositional and synechial angle-closure
- 8. Gonioscopy Complications Corneal abrasion Considerations in interpretation Normal angle landmarks (best viewed with parallelepiped method) 8 Prevention: moist cornea, topical anesthesia, minimize movement of lens on cornea Anterior to posterior: cornea, Schwalbe’s line, non-pigmented trabecular meshwork, pigmented trabecular meshwork, scleral spur, ciliary band, iris root
- 9. Gonioscopy 9
- 12. Gonioscopy 12
- 13. Gonioscopy 13
- 14. Gonioscopy Drawing showing gonioscopic view in combination with microscopic cross-section. Corneal wedge (arrow) Drawing by Lee Allen 14
- 15. Gonioscopy 15 Drawing by Lee Allen
- 16. Gonioscopy 16
- 17. Gonioscopy 17
- 18. Gonioscopy 18
- 19. Gonioscopy 19
- 20. Pentacam
- 21. Pentacam
- 22. Pentacam
- 25. Pentacam The Anterior Chamber Volume (ACV) has been fond to good screening tool for the diagnosis of narrow angles. With ACV of 110 mm3 as cut off : sensitivity of 88.32%, specificity of 90.62%, positive predictive value 92.7 Any patient with an ACV of <110mm3 had 9.42 time chance of having narrow angla on gonioscopy.
- 26. Acute Primary AngleClosure Glaucoma Etiology Physiologic pupillary block Excessive iris-lens apposition impedes flow of aqueous from PC to AC, elevating PC aqueous pressure Secondary forward bowing of peripheral iris results in occlusion of the TM Features Symptoms Blurred vision Colored haloes around lights 26 Acute onset of brow ache, eye pain Nausea and vomiting
- 27. Acute Primary-Angle Closure Glaucoma Signs 27 High IOP Mid dilated, sluggish pupil Corneal epithelial edema Congested episcleral and conjunctival vessels Shallow AC AC inflammation Appositional angle-closure Iris bombe Glaukomflecken and sector iris atrophy – indicators of previous bouts of acute-closure glaucoma
- 28. Acute Primary AngleClosure Glaucoma Risk factors Family history of angle-closure Older age Female gender Age-related cataract (lens swelling) 28 Hyperopia Asian ethnicity
- 29. Acute Primary AngleClosure Glaucoma Medical therapy options To lower the IOP and allow clearing of corneal edema in preparation for laser iridotomy Alpha2-adrenergic agonists CAIs – topical, oral, IV Miotics – 1-2% pilocarpine after IOP starts to normalize Prostaglandin analogues Hyperosmotic agents 29 Beta-adrenergic antagonists Topical corticosteroids
- 30. Acute Primary AngleClosure Glaucoma Deformation of cornea with cotton tip applicator or Indentation gonioscopy occasionally opens the angle Topical glycerin or epithelial removal may be necessary to enable visualization of the chamber angle Surgical therapy 30 Laser peripheral iridotomy–Nd:YAG and/or argon Cristallin Lens extraction
- 31. Acute Primary AngleClosure Glaucoma Complications Complications of laser iridotomy Posterior synechiae Miotics, especially strong miotics, may increase pupillary block Formation of PAS 31 Perform laser iridotomy as soon as possible
- 32. Acute Primary AngleClosure Glaucoma Disease-related complications Corneal decompensation Sectoral iris atrophy Posterior synechiae Cataract formation Optic nerve damage 32 Residual stage of angle-closure glaucoma Retinal vascular occlusion
- 33. Acute Primary AngleClosure Glaucoma Glaukomflecken under the anterior lens capsule after an attack of acute angle closure. These lens changes are caused by necrosis of the lens epithelium. 33
- 34. Acute Primary AngleClosure Glaucoma Pre Iridotomy Post iridotomy 34 Photos courtesy of Jeff Henderer, MD
- 35. Neovascular Glaucoma History Markedly reduced vision (usual) Diabetes 35 Pain, photophobia (usual) Hypertension, arteriosclerosis
- 36. Neovascular Glaucoma Epidemiology CRVO PDR Post cataract extraction, vitrectomy Carotid occlusive disease 36 Particularly with breached posterior capsule May have normal or low IOP CRAO
- 37. Neovascular Glaucoma Features: Early 37 Tufts of new vessels at pupillary margin Fine vessels crossing scleral spur Features: Late Very high IOP Conjunctival injection Corneal edema Florid iris neovascularization with ectropionuveae Fibrovascular membrane over iris and angle structures Variable synechial angle-closure With total angle closure, there can be minimal neovascularization of iris, and with pigmented Schwalbe's line, on gonioscopy can be mistaken for OAG AC cells and flare
- 38. Neovascular Glaucoma Risk factors Retinal hypoxia Disease-related complications Absolute glaucoma with blindness Intractable pain Patient instructions 38 Medication and surgical discussion Referral for PRP, surgical intervention, and/or cyclodestructive procedure
- 39. Neovascular Glaucoma Neovascularization of the iris and angle 39 Photo courtesy of Teresa Chen, MD