This case presentation describes a 63-year-old man diagnosed with primary angle closure glaucoma in both eyes. He was initially diagnosed in 2018 at a diabetic hospital during a regular checkup. Examination found occludable angles in both eyes. He underwent laser peripheral iridotomies (LPI) in both eyes and was prescribed various glaucoma medications. Follow up examinations showed intraocular pressures were maintained within normal limits and no progression of glaucomatous changes. His most recent examination in 2021 found intraocular pressures of 10mmHg in both eyes. The presentation emphasizes the importance of treating primary angle closure to prevent glaucomatous damage and acute attacks.

1. Primary Angle Closure
Case presentation
Speaker:
Dr. Syeda Fahmida Farzana Aziz

2. CASE PRESENTATION
Md. X
63 years
Muslim
Middle class
Businessman
Mohammadpur, Dhaka.
Date of Examination: 09/06/2021

3. FIRST DIAGNOSIS
At first diagnosed as a case of PACG Suspect
both eyes at a Diabetic hospital during regular
checkup as a diabetic patient during February
2018.
They referred him to a Glaucoma specialist.

4. FIRST VISIT TO A GLAUCOMA
SPECIALIST
On ocular examination:
V/A-6/6 both eyes (Aided).
GAT-26 mmHg OD, 24 OS at
8.30AM.
Diagnosis:
Occludeable angle both eyes.
Treatment:
Taflan Eye drop
One drop Once at night both
eyes.

5. FIRST FOLLOE-UP
On Examination:
V/A-6/6 both eyes (Aided).
IOP-18 mmHg BE at 5.30PM
Treatment:
Continue previous medication.
Plan:
Yag LPI BE.

6. ANY INVESTIGATION?
OCT OD & RNFL both eyes
(12.03.2018).

7. He took only one visit to
a renowned eye hospital of
India (21/12/2018).
Plan
Yag LPI both eyes.
Treatment
Latanoprost eye drop
Once daily.

8. SEEN AT GLAUCOMA DEPARTMENT OF
GOV.HOSPITAL OF BANGLADESH
Date-07.02.2019
On ocular examination-
1-0
1-0
1-0
2
1-0
2
1-0 1-
0
GAT-12 mmHg in OD,12
mm Hg in OS at 11.00AM

9. Treatment Zoladin eye drop
1 drop 3 times BE
Pilo 2% eye drop
1 drop 4 times BE
Xirom eye drop
1 drop 4 times
LPI (RE) done
Advise:
LPI LE

10. FIRST FOLLOW-UP
Date: 16.02.2019
Continued previous treatment.
Referred to Cornea clinic.

11. TREATMENT OF CORNEA CLINIC
•Cap. Doxy cap (100mg)
1+0+1 for 7 days
0+0+1 for 21 days
•Tearfresh liquegel eye drop
1 drop 4 times for 1 month BE
•Hot compression
2 times for 10 minueits 1 month
Diagnosis:
Meibomian gland dysfunction both
eye

12. SECOND FOLLOW-UP
Date: 23.02.2019
IOP-14 mmHg in OD, 14 mm
Hg in OS at 11.00AM
Continued previous treatment
LPI (LE) done

13. THIRD FOLLOW-UP
Advised to continue
Zoladin ED
1 drop 3 times BE
Timo ED
1 drop 2 times BE

14. SUBSEQUENT FOLLOW-UP
GAT of both eyes were within
normal limit.
No progression of glaucomatous
changes.

15. LAST FOLLOW-UP 09.06.2021
On Examination
GAT-10 mmHg in OD, 10 mm
Hg in OS at 11.00AM
Treatment
Timo eye drop
1 drop 2 times both eyes

16. LAST FOLLOW-UP 09.06.2021
CONT…

17. LAST FOLLOW UP
Now still no complaints of diminished vision .
No pain.
No halos.
No glare.
No redness
No headache

18. PAST OCULAR HISTORY
•He used spectacle for last 20
years.
•History of no surgery in his
eyes.

19. MEDICAL HISTORY
DM for 9 years.

20. FAMILY HISTORY
Elder brother and One Parental cousin is suffering from Glaucoma.

21. GENERAL EXAMINATION
Appearance: worried.
Body Built & Nutrition:
average.
Anemia: absent.
Jaundice: absent.
Cyanosis: absent.
Clubbing: absent.
Oedema: absent.
Dehydration: absent.

22. GENERAL EXAMINATION
Lymph nodes: not palpable.
Thyroid gland: not enlarged.
Pulse: 76 beats/min, regular &
normal in volume.
Blood pressure: 120/80 mm Hg.
Respiratory rate: 16/min.
Temperature: 98 degree F.

23. OCULAR EXAMINATION
Right Eye Left Eye
Visual acuity • 6/9 p
• 6/6 aided with +1.75
DSPH
• 6/12 p
• 6/6 aided with +2.00
DSPH
Near vision N/5 with +2.50 N/5 with +2.50
Eyelid, Eyelash Mild MDG, Blepharitis Mild MDG, Blepharitis
Conjunctiva Mild congestion
Nasal Pinguecula
Mild congestion
Nasal Pinguecula
Cornea Clear Clear

24. OCULAR EXAMINATION
Right Eye Left Eye
Anterior Chamber AC depth >1/4 corneal
Thickness
AC depth >1/4 corneal
Thickness
Iris LPI 9 O'clock position LPI 3 O'clock position
Pupil Pupillary reaction Brisk,
RRR
Pupillary reaction Brisk,
RRR
Lens NS 1 cataract NS 1 cataract

25. FUNDUS EXAMINATION
Right Eye Left Eye
Media Clear Clear
Disc margin Normal Normal
C:D Ratio 0.6:1 0.5:1
NRR Healthy, ISNT rule is still
maintain.
Healthy, ISNT rule is still
maintain.
Small blood vessels over
Optic Disc
No reduction No reduction
Retinal peripheral vessels are
normal.
Normal Normal
Foveal reflex- Present Present

26. OCULAR EXAMINATION
Right Eye Left Eye
GAT at 11.50AM 13 mm of Hg
(Cornea 553 um Thick)
12 mm of Hg(Cornea 556
um Thick)
Gonioscopy SL/0
SL/0
AT
M
PT
M
SL/0
SL/0
PTM/
ATM
SL/0

27. OCULAR EXAMINATION
Indentation Gonioscopy
SL-TM
SL-
TM
SL-TM
PAS
TM-SS
SL-
TM
SL-
TM
TM-
SS
TM-
SS

28. SYSTEMIC EXAMINATION

29. SYSTEMIC EXAMINATION

30. PROVISIONAL DIAGNOSIS
Primary Angle closure both eyes with DM

31. DIFFERENTIAL DIAGNOSIS
PACS both eyes
PACG both eyes

32. Investigations

33. HVFA 24-2 BOTH EYES

34. OCT OF OPTIC NERVE HEAD &
RETINAL NERVE FIBER LAYER IN BOTH
EYES

35. CFP BOTH EYES

36. OCT OF ANT SEGMENT BOTH EYES

37. OCT OF ANT SEGMENT BOTH EYES

38. UBM OF ANT SEGMENT BOTH EYES

39. Glaucoma is an eye condition that if left untreated, will lead to
blindness and that blindness is irreversible.
People who are aware that they have the disease still struggle with
trying to live with glaucoma and take care of it.

40. TAKE HOME MESSAGES
To prevent development or progression of glaucomatous damage and
Acute attack, Primary Angle Closure (PAC) must be treated with drugs
and Laser Peripheral Iridotomy .