Acute Angle-Closure Glaucoma (AACG)

Last updated 20.09.12

 

Definition

-  Glaucoma (optic neuropathy from IIOP) from obstruction of draingage from anterior chamber which acutely threatens eyesight

 

Features

-  Ocular emergency

-  Anatomical abnormalities (as below) causes apposition of lens & iris during dilation (mydriasis)

-  --> papillary block

-  --> no flow from post to ant chamber = increased intraocular pressure (IIOP)

-  More common in Asians

-  Females > males

 

Glaucoma

 

Causes

-  Anatomical abnormalities

-  Shallow anterior chamber

-  Thin ciliary bodies

-  Thin floppy iris

-  Anterior thicker lens

-  Short axial eye length

-  Precipitants

-  Drugs

-  Sympathomimetics, anticholinergics, antidepressants

-  Dimlight (mydriasis)

-  Rapid correcton of hyperglycaemia

-  Mechanical obstruction

-  RBCs from long term vitreous haemorrhage

 

Associated S/S

-  Elderly, hyperopic

-  Boring periorbital pain

-  +/- ipsilateral headache

-  Difficulty in fundoscopy due to cloudy & oedematous cornea

-  Firm globe to palpation

-  Reduced visual acuity: hand movements..

 

Dx

-  2+ symptoms of

-  Ocular pain

-  Nausea or vomiting

-  Intermittent blurring vision w halos

-  3+ signs of

-  Intraocular pressure > 21 mmHg

-  Corneal epithelial oedema

-  Mild dilated non-reactive pupil

-  Shallow ant chamber in presence of occlusion

-  Conjunctival injection (red eye)

 

Ix

-  Tonometry: IIOP > 21 mmg Hg

-  Tonopen or slit lamp

-  Slit lamp

-  Microcystic oedema

-  Narrow ant chamber

 

Mx

-  Opthalmic emergency

-  Pt to remain supine

-  Do not cover eye: causes dilation (mydriasis) & worsening IIOP

-  Acetazolamide (CAI)

-  Stat dose 500 mg IV

-  500 mg PO

-  Topical

-  Beta blocker: Cartelol..

-  Steroid 1-2 doses

-  Analgesics: headache, periorbital pain

-  Anti-emetics

-  Pilocarpine: careful use

-  1 hr post Acetazolamide + steroid + beta blocker

-  Mitotic (mitosis)

-  Sx iridotomy

-  24-48 hrs post control of Rx pressure

-  Hole burnt via laser through iris into post chamber to relieve IIOP

 

Iridotomy

 

 

 

 

Primary Open Angle Glaucoma (POAG)

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Features

-  Optic neuropathy from IIOP causing visual changes

-  Most common cause of glaucoma

-  Chronic progressive: Sneak thief of sight

-  May present after considerable vision loss

-  One of leading causes of preventable blindness

 

Associated S/S

-  Characteristic visual field loss

-  Multicolored halos in vision

-  Headache

-  Fundoscopy: cupping & atrophy of optic disc

-  Afferent pupillary defect

 

Ix

-  Tonometry: IIOP > 21 mmg Hg

-  Tonopen or slit lamp

-  Slit lamp

-  Stereofundus photogtaphs

-  Visual field analysis

-  If normotensive glaucoma need further Ix to exclude DDx

-  FBE, ESR

-  +/- neuroimaging

-  Syphilis serology (not VDRL)

 

Mx

-  Acetazolamide (CAI)

-  Topical

-  Beta blocker: Cartelol..

-  Steroid 1-2 doses

-  Alpha agonists: Brimonidine

-  Mitotic agents: Pilocarpine

-  Prostaglandin analogs: Latanoprost

-  Sx

-  Trabeculoplasty or trabeculectomy

-  Drainage implant