Primary Angle-Closure Glaucoma: What to Know

This article discusses primary angle-closure glaucoma, the second most common form of this eye disease. The author discusses important information to know about symptoms, diagnosis, treatment options, known risk factors, and more.

Primary angle-closure glaucoma is associated with closure of the anterior chamber angle of the eye, in contrast to the most common form of glaucoma known as primary open-angle glaucoma. This angle is an important structure in the eye, and is present 360 degrees around the circumference of the eye. The angle can be thought of as the angle between the iris and the cornea, although that is an oversimplification.

Nevertheless, in the angle one finds the drainage system of the eye, called the trabecular meshwork, which, if your angle is open, is visible to your eye doctor by using a special mirrored lens.

The video below provides a very good representation of the eye’s “angle. ”

Video: Angle-Closure Glaucoma

View a transcript of the video

Angle-Closure Glaucoma: What Causes the Eye’s Drainage Angle to Narrow?

In primary angle closure, the trabecular meshwork is not as visible because of a “narrowing” of the angle. There are multiple reasons for this “narrowing.”

• Pressure Differences

  This includes a pressure difference between the back of the eye (posterior chamber) and the front of the eye (anterior chamber), which can cause the iris to bow forward and cause further angle narrowing.

• Anatomical Changes

  In far-sighted patients, the eye is shorter than typical, which means the front of the eye is “crowded” and the angle tends to be narrower. Additionally, the thickness of the ciliary body (the part of the eye that produces the eye fluid, called aqueous humor), the position of the iris relative to the ciliary body, the volume of the iris, and the shape, position, and thickness of the lens, all can contribute to angle narrowing.

  Some of these anatomical features change with age, such as the thickness of the lens, which increases as we get older (forming cataracts). This is why sometimes patients develop progressive angle narrowing over time.

  In other situations, the closure of the angle can happen acutely, resulting in an acute angle-closure crisis. This is a very worrisome situation in which the eye pressure rapidly increases and vision can be severely affected. We will discuss this important condition later in this article.

Angle Closure: A Few Definitions

First, we will define a few more terms. Angle closure may or may not be associated with increased eye pressure or damage to the optic nerve, and can occur in either an acute or chronic form. Indeed, if one has evidence of angle narrowing but no evidence of increased eye pressure or optic nerve damage, your ophthalmologist may diagnose you as a “primary angle-closure suspect.”

If you have angle narrowing and elevated eye pressure, but no optic nerve damage, you may be diagnosed with “primary angle-closure. ”

Finally, if you have angle narrowing, elevated eye pressure, and optic nerve damage, you have “primary angle-closure glaucoma.”

Angle-Closure Glaucoma: Risk Factors

Regardless of the exact diagnosis, the risk factors for primary angle-closure glaucoma include:

• a family history of angle closure
• older age
• female gender
• Asian descent.

Other risk factors related to the eye’s anatomy include:

• hyperopia (farsightedness)
• shallow anterior chamber
• thick lens
• short length of the eye
• ciliary body anatomy

Angle-Closure Glaucoma Symptoms

Sometimes angle closure can result in no symptoms, and other times the symptoms are very obvious (as in an acute-angle closure crisis). There can also be intermittent or occasional symptoms, such as blurred vision, halos around lights, eye pain, headache, eye redness, or symptoms occurring after dilation of the eyes. In addition, many medications with glaucoma warnings apply to patients with primary angle-closure. Briefly, these include over the counter decongestants, motion-sickness medications, and anticholinergic agents, just to name a few. Always ask your ophthalmologist about any glaucoma side-effect warnings if you are unsure.

Diagnosis of Angle-Closure Glaucoma

During your eye examination, your eye doctor will assess all parts of the eyes as they would during a comprehensive eye examination, although sometimes a dilated exam will not be performed if your ophthalmologist is very concerned about the narrowness of your angles. In addition, your doctor will perform gonioscopy, which uses a special mirror in order to visualize the angle. Sometimes, imaging of the front part of the eye, called anterior segment optical coherence tomography are, or ultrasound biomicroscopy (a special type of ultrasound eye exam) will be performed to more specifically determine the anatomy of the angle.

Treatment of Angle Closure Glaucoma

After your eye examination, your ophthalmologist will discuss any recommendations for laser peripheral iridotomy, medications, or surgery, which will briefly be discussed below.

Acute Angle-Closure Crisis

In an acute-angle closure crisis, the eye pressure can increase rapidly and to high levels. The patient may experience symptoms such as blurred vision, halos around lights, eye pain, headache, nausea, and possibly vomiting. Untreated, an acute angle-closure crisis can cause permanent vision loss or blindness. In addition, the other eye is at high risk for having a similar crisis. This is why laser peripheral iridotomy is recommended both as a treatment during an acute crisis and in patients who are asymptomatic, but have primary angle closure and are at risk for an acute angle-closure attack.

A laser iridotomy (see video) creates a hole in the iris, which acts as an alternative channel through which eye fluid can flow when the usual pathway becomes blocked.

The risks of the laser iridotomy are relatively low, whereas the harm that an attack can do is relatively high and potentially permanent. In terms of treatment, the initial steps are to break the attack, which will be accomplished using a combination of eye pressure lowering medications and laser iridotomy.

Sometimes removing the lens (or cataract) is recommended in an acute angle-closure crisis. It will be important to discuss with your ophthalmologist the best treatment option for you and your long-term follow-up plan.

Primary Angle-Closure Suspects

Primary angle-closure suspects should have a discussion with their ophthalmologist about the risks and benefits of laser iridotomy, which is a procedure designed to prevent an acute angle-closure crisis. If you need to take medications that might increase your risk of having an attack or you have symptoms that suggest intermittent angle closure, this may push the balance towards undergoing this preventive procedure. Otherwise, sometimes it can be reasonable to follow-up over time to see if the angle becomes progressively more narrow.

Primary Angle-Closure and Primary Angle-Closure Glaucoma

Treatment for patients with primary angle-closure and primary angle-closure glaucoma involves removing a small portion of the outer edge of the iris using laser iridotomy. Patients who have an acute angle-closure crisis in one eye may have treatment performed in the other eye as a precautionary action, as they are at higher risk of having a similar event occurring in the other eye.

Summary

For more information of why an iridotomy helps prevent and/or treat an acute angle-closure crisis, please refer to a detailed article on this topic. Regardless of the specific diagnosis related to primary angle-closure you receive, it is important to discuss with your ophthalmologist the follow-up plan, because chronic forms of the disease can develop and it will be important to catch this earlier rather than later.

About the author

Yvonne Ou, MD

University of California, San Francisco, UCSF Medical Center

Yvonne Ou, MD, is a board certified ophthalmologist who specializes in glaucoma, including medical, laser, and surgical therapies; cataract evaluation and treatment including combined cataract and glaucoma surgery; glaucoma filtering and implant surgery; and newer procedures.

Full Bio

Risk Factors, Symptoms, and Treatment

Closed-angle glaucoma is an uncommon type of glaucoma where the pressure inside of your eyes begins to buildup, causing pain to the eyes.

Closed-angle glaucoma is a condition in which the pressure inside of your eye becomes too high.

There are a number of diseases that fall under the heading “glaucoma.” Open-angle glaucoma is the most common form of the condition and it accounts for around 90 percent of all cases of glaucoma. Closed-angle glaucoma is much less common.

If left untreated, all types of glaucoma may cause damage to your optic nerve — the nerve that transmits visual information to your brain — and ultimately blindness.

If you have closed-angle glaucoma, pressure builds because fluid isn’t flowing out of your eye as it should.

Fluid is produced in the rear chamber of your eye, behind the iris. This fluid normally flows through your pupil into the front chamber of the eyeball.

The fluid then goes through a series of channels called the trabecular meshwork and into the veins of the sclera (the white of your eye).

In closed-angle glaucoma, the trabecular meshwork is obstructed or damaged. The fluid can’t flow as easily through this drainage pathway, or is completely blocked. This fluid backup increases pressure within your eyeball.

Closed-angle glaucoma can be divided into two main types:

Primary closed-angle glaucoma

In primary closed-angle glaucoma, the structure of the eye makes it more likely that the iris will become pressed against the trabecular meshwork. This could be because:

• the angle between the iris and cornea is very narrow
• the eyeball is relatively short as measured from front to back
• the lens inside the eye is thick, pushing the iris forward
• the iris is thin, making it fold into the angle

Secondary closed-angle glaucoma

In secondary closed-angle glaucoma, an underlying condition causes changes in your eye that force the iris against the trabecular meshwork. These underlying conditions may include:

• eye injury
• inflammation
• diabetes
• tumor
• advanced cataract (clouding of the eye’s lens)

Closed-angle glaucoma can also be described as acute or chronic. Acute cases are more common and occur suddenly. Chronic closed-angle glaucoma develops gradually, making the symptoms harder to spot.

Your risk for closed-angle glaucoma is greater if you:

• are older than 40 years of age, especially if you’re between 60 and 70 years old
• are farsighted
• are female
• have a brother, sister, or parent with the disease
• are of Southeast Asian or Alaska Native origin

If you have the acute form of the condition, you’ll likely experience a sudden onset of one or more of the following symptoms:

• severe eye pain that comes on suddenly
• blurred vision
• bright halos appearing around objects
• eye redness, tenderness, and hardness
• feeling nauseated and vomiting

The attack may occur when your pupils are moderately dilated — for example, when you’re in a darkened room, when you’re under stress, or after taking certain drugs.

If you do experience any of these symptoms, you should call 911 or visit an emergency room right away. Acute closed-angle glaucoma is an emergency.

Symptoms of chronic closed-angle glaucoma are subtler. You may not notice any changes, or, if the condition progresses, you may realize that your sight is deteriorating and that you’re losing the edges of your field of vision.

Occasionally, some people experience eye pain and redness, but not as severely as in acute closed-angle glaucoma.

Your doctor will ask you questions about your condition, examine your eyes, and measure your eye pressure. No special tests are needed. If treated urgently, your eye can recover.

Acute cases of closed-angle glaucoma are emergencies, and you should go to the hospital or visit an ophthalmologist as quickly as possible. You could lose your sight if you delay treatment.

Medication and surgery are used to treat closed-angle glaucoma.

Medications

You may need a number of different drugs including:

• acetazolamide, which reduces the fluid in your eye
• beta blockers, which lower the amount of fluid your eye produces
• steroids, which reduce inflammation
• painkillers (as a comfort measure)
• drugs to treat nausea and vomiting
• pilocarpine, which opens the angle between your iris and cornea

Surgeries

Once the pressure in your eye has decreased, you’ll need further treatment to prevent the pressure from rising again. There are two surgeries used to address closed-angle glaucoma:

• Peripheral Iridotomy. This is a laser treatment that creates tiny drainage holes in your iris. It is used to treat both acute and chronic closed-angle glaucoma.
• Surgical Iridectomy. In this less-common treatment, a surgeon makes a small triangular opening in your iris.

If you have a family history of glaucoma, you should have your eyes checked regularly. Your doctor may recommend peripheral iridotomies to help prevent an attack if you’re at an especially high risk for closed-angle glaucoma.

Angle-closure glaucoma

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Angle-closure glaucoma

Angle-closure glaucoma – causes, symptoms, treatment, surgery in Kyiv

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In Ukraine, glaucoma remains the leader among diseases that lead to visual impairment. Among the forms of this pathology, angle-closure glaucoma is less common, but occurs at an earlier age – from 30-35 years.

To understand what angle-closure glaucoma is, it is enough to know the anatomical nuances of the structure of the eye. It produces a special fluid that nourishes the internal structures. With the help of a drainage system in the anterior corner of the eye, this fluid flows to the scleral veins. Microcirculation and outflow can be disturbed if the anterior corner of the eye is blocked by the structures of the organ of vision – the lens, the iris.

Fluid accumulates, causing high intraocular pressure (IOP) – the main symptom of glaucoma, including angle-closure glaucoma. At the first stages of the development of the pathological process, it does not make itself felt, so it is very important to determine it in advance at the doctor’s appointment.

Clinic “Excimer” performs early diagnosis of angle-closure glaucoma in Kyiv on innovative professional-class equipment, and also selects an individual treatment plan in each case.

Causes of angle-closure glaucoma

The main cause of the disease is the blockage of the angle of the eye chamber, caused by anatomical features. It is the individual structure of the organs of vision that leads to the disease: a large lens, a thickened iris, a small camera, a shortened eyeball.

Other factors also influence the development of the disease. If angle-closure glaucoma occurs, the causes may be as follows:

• Concomitant pathologies – cataracts, diseases of the endocrine system, eye trauma.
• Nationality. Pathology is often found in representatives of East Asian countries.
• Congenital pathologies of the organs of vision of a genetic nature. The angle of the anterior chamber of the eye is blocked due to disorders that occur in the 3rd trimester of pregnancy.

Symptoms of angle-closure glaucoma

The disease can remain unnoticed for a long time, flowing into a chronic form, or makes itself felt with an acute attack.

If angle-closure glaucoma is suspected, symptoms of a chronic process may include:

• eye discomfort;
• blurred vision and its reduction;
• narrow field of view;
• severe headache that improves during sleep and lying down;
• iridescent halos before the eyes, especially when looking at a distant light source;
• Periodic flashes of lightning before eyes.

An acute attack leads to permanent loss of vision and is extremely dangerous: within a few hours, IOP exceeds 40 mm Hg. Art. (at a rate of 18-22 mm Hg!). In this case, you should immediately seek medical help and reduce IOP.

Types and features of angle-closure glaucoma

There are three types of disease.

Primary angle-closure glaucoma

The primary form of the disease occurs as an independent process. There are three degrees of pathology in relation to IOP indicators according to Maklakov:

• A – IOP indicators are practically within the normal range – not higher than 27 mm Hg. st;
• B – IOP fluctuates between 28-32 mm Hg. Art.;
• C – pressure indicators exceed 32 mm Hg. Art.

Angle-closure glaucoma 1 A means that the process is only developing, and intraocular pressure can still be controlled. If the disease is diagnosed at this stage, it can be treated with favorable prognosis.

Primary angle-closure glaucoma is also divided into subtypes:

• With functional pupillary block. The camera angle is occluded by the iris root, which is the most common form.
• Creeping. Due to the fusion of the iris root with the anterior wall of the angle, the chamber angle is reduced.
• Flat iris. It is observed with a thick root of the iris.
• With vitreocrystalline block. A very rare form that occurs due to anatomical nuances: a small eye and a large lens.

Secondary angle-closure glaucoma

Secondary glaucoma is a disease that develops in the presence of other processes:

• Inflammatory. It leads to inflammation of the vascular network in the shell of the eye (uveitis).
• Phacogenic. Appears after diseases that affect the lens of the eye – including hyphema, subluxation of the lens, cataracts.
• Traumatic. The development of the process is possible after surgery on the eye, as well as after injury to the organ.
• Medical. Occurs against the background of long-term treatment with hormones, corticosteroids, alpha-chymotrypsins.
• Neovascular. It is rare, almost impossible to correct. Vessels of an abnormal nature are formed that prevent the exit of fluid.

Acute angle-closure glaucoma

As mentioned above, during an acute attack, IOP increases sharply, which manifests itself:

• severe sharp pain in the damaged eye;
• momentary decrease in vision;
• colored halos around the light source;
• headache with nausea and vomiting;
• severe reddening of the eyes.

An acute attack can be mistaken for other pathologies. If these symptoms appear, it is urgent to call an ambulance.

Stages of angle-closure glaucoma

The classification of glaucoma is very broad and includes several parameters. There are four stages of nerve damage:

Stage	Description
I (start of process)	visual fields are still within the normal range, but slight changes are already observed. there is a depression in the optic disc (excavation).
II (development)	angle-closure glaucoma of the second degree makes changes in the field of view, reduces its boundaries. the paracentral section is narrowed by 10 degrees or more. deepening in the optic nerve head is clearly expressed.
III (much advanced)	The field boundary is narrowed to 15 degrees from the fix point. pathological changes in the optic nerve (excavation) reach the edges.
IV (final)	total excavation, complete loss of vision. it is possible to maintain a small lumen of the field of view and reaction to light.

Diagnosis of angle-closure glaucoma

For the diagnosis of glaucoma, the state of eye hydrodynamics and visual function is studied in detail using special methods. The Excimer Clinic (Kyiv) has high-tech equipment for the most accurate examination of the fundus and other structures of the eye.

If angle-closure glaucoma is suspected, the diagnosis in the clinic follows the recommendations of the International Council of Ophthalmology:

• study of the visual field using a computerized perimeter;
• measurement of IOP with a tonometer;
• determination of the thickness of the lens, as well as measurement of the depth of the anterior chamber with a pachymeter;
• Examination of the angle of the anterior chamber by gonioscopy.

Additional diagnostic methods are also used to examine the optic nerve, lens and iris.

Treatment of angle-closure glaucoma

Treatment is determined by the cause of angle closure and individual risks for the individual patient. In accordance with international guidelines for the treatment of angle-closure glaucoma, therapy also depends on the stage of the disease.

Medication

Medications are not able to restore the full balance of the fluid inside the eye, they only maintain it. The drugs help to reduce the production of fluid and its better outflow. When treating with medications, regular examinations and a visit to an ophthalmologist are necessary.

Laser

Laser treatment is considered to be gentle, effective and modern. In Ukraine, such treatment is carried out at the Excimer Ophthalmological Center (Kyiv).

The clinic uses several techniques:

• Laser iridectomy. The laser acts on the iris, forming a hole in it for the normal exit of fluid. This opens the angle of the anterior chamber, so iridectomy is indicated at the earliest stages as a preventive measure: when the angle has not yet closed, but there is such a risk.
• Laser trabeculoplasty. Normalizes IOP with the action of a special laser on the trabecular network. The intervention takes a few minutes, the next day the patient can return to his usual way of life.

Surgical (surgery)

Surgical treatment of glaucoma is one of the most popular treatment methods. Excimer Kyiv clinic uses only the leading modern solutions in the field of ophthalmic surgery:

1. Non-penetrating deep sclerectomy (NPDS). The corneal membrane is surgically thinned, the outflow of fluid is restored naturally. During the operation, the patient may be implanted with collagen drains to prevent tissue scarring. Such systems also allow prolonging the effect of surgery.
2. Implantation of the Ex-Press Fluid Filtration Device. This method has been used in the surgical practice of glaucoma correction for more than ten years. Ex-Press is installed as an additional drain. It is implanted under the scleral flap and secured to drain fluid. The device allows avoiding high injuries and complications after the intervention, as well as reducing the number of scheduled visits to the optometrist in the future. It is considered one of the safest methods.
3. Ahmed valve implantation. The system controls the level of IOP, providing a connection between the chamber of the eye and the sub-shadow space.
4. IOL implantation is an additional procedure. Often, glaucoma shows cataract phacoemulsification. A large lens can prevent the exit of intraocular fluid and provoke the development of glaucoma, so it is removed.

Contraindications

If closed-angle glaucoma is diagnosed, contraindications for surgery are as follows:

• additional serious pathologies of the organs of vision;
• the risk of reduced visual acuity exceeds the possibility of a positive postoperative effect.

Before the intervention, it is necessary to pass a series of tests, and in case of diabetes, an endocrinologist’s consultation is obligatory.

Angle-closure glaucoma – prohibitions and recommendations

When a patient is diagnosed with angle-closure glaucoma, he should reconsider his lifestyle and some habits. The disease can be controlled with medications at the discretion of the doctor. At the same time, there are measures that help to stop the development of the process.