Angle Closure Glaucoma

Angle closure glaucoma is a disorder of progressive optic nerve damage characterized by an increased intraocular pressure. Obstruction of aqueous humor flow in the anterior chamber causes sudden vision impairment and headaches. A rapid diagnosis is necessary, as blindness can occur without adequate treatment.

The disease is caused by this process: endocrine.

Presentation

The clinical presentation of angle closure glaucoma stems from sudden increases in intraocular pressure (IOP), with possible triggers being dim lighting or use of drugs that induce pupillary dilation (eg. anticholinergics), ciliary body swelling (eg. topiramate) [1]. Moreover, anterior placement of the lens (most commonly caused by the gradual development of cataract) [2], myopia, hyperopia, a shallow anterior chamber, but also advanced age and female gender have all been established as potential risk factors for this type of glaucoma [3] [4]. Only about a third of cases develop an acute exacerbation of IOP changes, however, but increased IOP may not cause marked eye-related symptoms in the beginning [5]. Unfortunately, patients frequently report when profound visual deficits have already occurred, especially in chronic forms, thus reducing the chance of total sight repair [4] [5]. Most prominent symptoms of acute angle closure glaucoma are blurred vision, redness of the eye, ocular discomfort, colored halos around lights and frontal headaches accompanied by nausea and vomiting. Gastrointestinal complaints and headaches may mislead the physician by suggesting a gastrointestinal or central nervous system origin of symptoms [1] [3], and it is not uncommon for glaucoma patients to undergo detailed gastrointestinal or CNS workup prior to their diagnosis [2]. In some patients, a prolonged (chronic) clinical course may be observed, distinguished by ocular discomfort and headaches that are alleviated with sleep [1]. In the setting of a delayed diagnosis, irreversible blindness can occur rapidly, which is why early recognition is detrimental in achieving good outcomes [4].

Workup

Patients must be promptly evaluated through a detailed examination of the eye [5]. IOP of more than 30 mmHg (physiological range is between 10 and 23 mmHg) is encountered in virtually all patients suffering from glaucoma, while other findings include a fixed mid-dilated pupil (4-6 mm) that reacts poorly to direct illumination, a hazy cornea that may be edematous, hyperemia of the conjunctiva and a shallow anterior chamber [3]. The presence of adhesions between the iris and the angle structure, termed peripheral anterior synechiae (PAS), can cause obstruction of the trabecular meshwork and are frequently encountered in angle closure glaucoma patients as well [3]. These findings can be confirmed either by performing gonioscopy or through a slit-lamp examination [5], while more specialized techniques have been developed to confirm angle closure. Ultrasound biomicroscopy, which is able to acquire real-time images of structures that potentially cause obstruction of the canal, and anterior segment optical coherence tomography, used to evaluate the anterior chamber, are imaging methods that are recommended for glaucoma workup by more skilled ophthalmologists [5].

Treatment

Prognosis

Etiology

Epidemiology

Sex distribution
Age distribution

Pathophysiology

Prevention

Summary

Patient Information

Self-assessment

References

  1. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  2. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
  3. Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76(6):829.
  4. Azuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016;388(10052):1389-1397.
  5. Weinreb RN, Aung T, Medeiros FA. The Pathophysiology and Treatment of Glaucoma: A Review. JAMA. 2014;311(18):1901-1911.

  • Acute angle-closure glaucoma: the second eye: an analysis of 200 cases - RF Lowe - The British Journal of Ophthalmology, 1962 - ncbi.nlm.nih.gov
  • Angle-closure glaucoma in an urban population in southern India: the Andhra Pradesh Eye Disease Study - L Dandona, R Dandona, P Mandal - , 2000 - journals.elsevierhealth.com
  • Severity and spatial distribution of visual field defects in primary glaucoma: a comparison of primary open-angle glaucoma and primary angle-closure glaucoma - G Gazzard, PJ Foster, AC Viswanathan - Archives of , 2002 - Am Med Assoc
  • Acute angle-closure glaucoma following botulinum toxin injection for blepharospasm. - P Corridan, S Nightingale, N Mashoudi - British journal of , 1990 - bjo.bmj.com
  • An ultrasound biomicroscopic analysis of angle-closure glaucoma secondary to ciliochoroidal effusion in IgA nephropathy. - CJ Pavlin, M Easterbrook, K Harasiewicz - American journal of , 1993 - ukpmc.ac.uk
  • Anterior chamber depth measurement as a screening tool for primary angle-closure glaucoma in an East Asian population - JG Devereux, PJ Foster, J Baasanhu - Archives of , 2000 - Am Med Assoc
  • Five‐year risk of progression of primary angle closure to primary angle closure glaucoma: a population‐based study - R Thomas, R Parikh, J Muliyil - Acta Ophthalmologica , 2003 - Wiley Online Library
  • Acute angle closure glaucoma associated with nebulised ipratropium bromide and salbutamol. - P Shah, L Dhurjon, T Metcalfe - BMJ: British Medical , 1992 - ncbi.nlm.nih.gov
  • Acute myopia and angle-closure glaucoma induced by topiramate - M Boentert, H Aretz, P Ludemann - Neurology, 2003 - AAN Enterprises
  • Aetiology of the anatomical basis for primary angle-closure glaucoma. Biometrical comparisons between normal eyes and eyes with primary angle-closure glaucoma. - RF Lowe - The British journal of ophthalmology, 1970 - ncbi.nlm.nih.gov
Self-assessment