What is Angle-Closure Glaucoma?: Ventura Eye Institute, Inc.: LASIK Surgeons

What is Angle-Closure Glaucoma?: Ventura Eye Institute, Inc.: LASIK Surgeons

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Glaucoma is a serious eye condition, usually degenerative, that can lead to blindness. In fact, glaucoma is one of the leading causes of blindness in people over the age of 60. Glaucoma damages your optic nerve, a very important nerve that transmits images to your brain. 

Vision loss from glaucoma can’t be reversed, so it’s important to visit your ophthalmologist regularly to check for any signs of degeneration or damage. Dr. Michael Ragen and Dr. Kyle Hunyh of Ventura Eye Institute have expertise in treating the different forms of glaucoma, including angle-closure glaucoma. 

What is angle-closure glaucoma?

Of the four types of glaucoma, angle-closure glaucoma is one of the rarer forms. Glaucoma is usually the result of too much pressure inside your eye, because excess pressure can lead to damage of your optic nerve. 

Angle-closure glaucoma occurs when the drainage system in your eye is too narrow for fluids to properly leave your eye. Fluid buildup leads to excess pressure, and glaucoma develops. You can think of it as something clogging up your shower drain — when the drain is blocked, fluid accumulates in the tub. 

Angle-closure glaucoma is also called narrow-angle glaucoma or acute glaucoma, the latter because this condition often arises very quickly and without much warning. This type of glaucoma is often considered an emergency that needs prompt treatment. 

Symptoms of angle-closure glaucoma

Angle-closure glaucoma can bring about severe and sudden symptoms, including: 

• Excruciating eye pain
• Headaches
• Nausea, vomiting, and vertigo
• Redness around the eyes
• Blurry or distorted vision

If you start to experience any of these symptoms, call your ophthalmologist right away.

Risk factors for angle-closure glaucoma

Some people have a higher risk for angle-closure glaucoma (or any type of glaucoma) than others. Risk factors for angle-closure glaucoma include: 

• Age: Glaucoma is more common in older people
• Ethnicity and race: Glaucoma is more common in black, Asian, and Hispanic people
• Family history of glaucoma
• Some medical conditions, such as high blood pressure
• Thin corneas
• Extreme nearsightedness or farsightedness
• Previous eye surgeries

Treatment for angle-closure glaucoma

Treatment for angle-closure glaucoma usually involves eye surgery that unblocks your drainage system. At Ventura Eye Institute, Dr. Ragen and Dr. Huynh specialize in laser trabeculoplasty, a type of laser surgery that drains excess fluid from your eyes. 

Your eye doctor may also prescribe oral medications or eye drops, or recommend that you get a stent implant to keep your fluid drains open.  

To learn more about angle-closure glaucoma and treatments, schedule a consultation appointment at Ventura Eye Institute. Call our Camarillo, California, office at 805-250-9723 or book your appointment online. You can also send the team a message here on the website.

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Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)

Contents

• Aetiology
• Predisposing factors
• Symptoms of primary angle closure
• Signs of primary angle closure
• Differential diagnosis
• Management by optometrist
• Management category
• Possible management by ophthalmologist
• Evidence base
• Summary

Aetiology

Primary Angle Closure Glaucoma (PACG) is a chronic optic neuropathy associated with a loss of retinal ganglion cells and their axons which typically affects the elderly. PACG has been estimated to affect 0.4% of European-derived populations aged 40 and over and 0.94% of those ≥70 years. Rates are 2-3 times higher in Chinese and South Asian populations compared to Europeans.  PACG carries a greater risk of severe visual impairment compared with Chronic Open Angle Glaucoma.

Angle closure is caused by a variety of mechanisms although pupil block, in which aqueous is impeded on its passage between the lens and posterior surface of the iris, is most common (up to 75% of cases). Non-pupil block causes include plateau iris and lens-induced (i.e. through intumescence or instability) angle closure.

Staging of angle closure disease:

• Primary Angle Closure Suspect (PACS)
• Primary Angle Closure (PAC)
• Primary Angle Closure Glaucoma (PACG).

Primary Angle Closure Suspect (PACS): represents the first stage, in which there is reversible contact between the peripheral iris and trabecular meshwork (irido-trabecular contact [ITC] in at least two quadrants). IOP is normal, there are no acquired adhesions between the iris and angle structures (peripheral anterior synechiae [PAS]), and no evidence of optic nerve damage.

Primary Angle Closure (PAC): is the second stage in which the IOP is elevated and/or PAS are present.  There is no evidence of glaucomatous optic neuropathy at this stage.

Primary Angle Closure Glaucoma (PACG): is the final stage in which glaucomatous optic neuropathy has developed.  In its chronic form, IOP may be normal or elevated and is often painless and asymptomatic.

(ITC = irido-trabecular contact, PAS = peripheral anterior synechiae)

An acute presentation of angle closure is a well-known ophthalmic emergency.  Acute Angle Closure crisis (AAC) results from a sudden rise in IOP (unilateral in 90% of cases) with acute symptoms (blurring, haloes and pain)

Predisposing factors

Anatomical 
Associated with: 

• sex (F:M ratio 3:1)
• ethnicity (e.g. Chinese, Vietnamese, Inuit).  PACG is recognised as a leading cause of blindness in East Asia
• family history
• short axial length (hypermetropia)
• shallow AC (F>M)
• increasing age (AC becomes shallower as lens thickness increases)
• small corneal diameter.

Iatrogenic (secondary angle closure)

Drug induced

• topical mydriatics
• increasing pupillary block e.g. adrenergic agents such as phenylephrine, systemic drugs with anticholinergic effects such as tricyclic antidepressants, selective serotonin reuptake inhibitors
• non-pupillary block mechanism e.g. drugs that may cause ciliary body oedema, such as topiramate, sulphonamides.

Surgery induced

• Angle closure may follow a number of surgical procedures, for example vitreo-retinal surgery with intraocular gas, especially in aphakic eyes.

Symptoms of primary angle closure

Typically patients with angle closure disease are asymptomatic, due to the chronic nature of the condition. Patients become symptomatic only when the disease is more advanced (e.g. ocular/periocular pain, headache).

AAC is associated with sudden onset of symptoms and signs:

• rapid progressive impairment of vision of one or both eyes 
• ocular and periocular pain which can be severe
• nausea and vomiting 
• ocular redness.

50% of patients with an acute angle closure attack give a history of previous intermittent attacks, e.g. episodes of blurring of vision lasting 1-2 hours, associated with haloes around lights, eye ache or frontal headache. 

Gonioscopy remains the reference standard for confirming ITC and diagnosing angle closure, although non-invasive tests e. g. slit-lamp grading of limbal anterior chamber depth (van Herick technique) or anterior segment imaging using OCT are useful for case-finding.

In PACS the eye may appear normal (with the exception of a narrow drainage angle, as judged by limbal anterior chamber depth <25% of corneal thickness (van Herick <grade 2) or ITC visible on anterior segment OCT).

PAC is additionally associated with elevated IOP and/or PAS.

In AAC the following signs may be present:

• limbal and conjunctival vessels dilated, producing ciliary flush
• ‘red eye’ 
• pupil fixed, semi-dilated, vertically elliptical, iris whorling
• corneal oedema 
• shallow AC with peripheral irido-corneal contact (if angle can be visualised) 
• high intraocular pressure (40-80mmHg) 
• AC flare and cells 
• optic disc oedematous and hyperaemic 
• grey/white anterior sub-capsular lenticular opacities (Glaukomflecken): diagnostic of previous attacks.

Differential diagnosis

Neovascular glaucoma 
Phakolytic glaucoma 
Phakomorphic glaucoma
Acute anterior uveitis
Uveitis with raised IOP 
Malignant glaucoma (cilio-lenticular block or aqueous misdirection glaucoma)

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non-pharmacological

PACS

In the light of new evidence of a low risk of glaucomatous optic neuropathy or AAC in people with PACS, the decision to refer for possible treatment with laser peripheral iridotomy, or lens extraction as an alternative, should be based on the risk of developing PAC/PACG or AAC (see Management Category). In PACS without additional risk factors for angle closure, referral and treatment are usually unnecessary (though patients should be informed of the symptoms of AAC and advised to return immediately should these occur). However, there may be a case for expediting cataract surgery in patients with significant lens opacities

(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

If not referring for further investigation, a person with PACS should be advised to seek an annual examination. Patients should be made aware that although they are at a low risk of angle closure, certain medications (e.g. pupil dilatation for fundus examination, SSRI antidepressants) could induce angle closure

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

PAC/ PACG

The current clinical consensus is that patients with PAC/PACG should be treated surgically (clear lens/cataract removal and/or YAG laser peripheral iridotomy [LPI]) to relieve pupillary block together with pharmacological therapy to reduce elevated IOP

(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

Pharmacological

AAC

Prior to referral, commence first aid treatment with a drop of pilocarpine 2% eye drops in blue eyes and 4% eye drops in brown eyes (although this is likely to be ineffective when IOP is over 40mmHg).  Consider repeating the dose after 15 min

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Although the use of topical pilocarpine may be beneficial in pupil block and plateau iris situations (75% of cases), it may be harmful when the cause is lens-induced or retro-lenticular.

Analgesia and anti-emesis if necessary.  Where the patient is not vomiting, give a single dose of oral acetazolamide (Diamox) 500mg (not slow release formulation). (NB: acetazolamide may be hazardous in elderly patients, and is contraindicated in people with sickle cell disease or trait.) Then refer as an emergency to ophthalmologist.  (In view of potential unwanted effects of this treatment, patient should be accompanied by a carer or relative).

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Management category

AAC

A2: first aid measures and emergency (same day) referral to ophthalmologist 

PAC/PACG

A3: urgent (within one week) referral to ophthalmologist; no intervention 

PACS

B1: routine referral to ophthalmologist (no intervention) only if limbal anterior chamber depth is <25% or an anterior segment OCT showing ITC, PLUS at least one of the following criteria:

• people with only one ‘good’ eye
• vulnerable adults who may not report ocular or vision symptoms
• family history of significant angle closure disease
• high hypermetropia (> +6. 00 dioptres)
• diabetes or another condition necessitating regular pupil dilation
• those using antidepressants or medication with an anticholinergic action (see http://www.acbcalc.com/ for details of drugs with anticholinergic properties)
• people living in remote locations where rapid access to emergency ophthalmic care is not possible.

If an individual has the angle-characteristics specified above but none of the above additional criteria, and does not meet NICE glaucoma referral guidelines (based on IOP ≥24mm Hg or presence of signs of glaucoma) they should be advised to seek an annual examination.

Although pharmacological pupil dilatation as part of routine eye care can cause a small increase in IOP in PACS eyes (typically <5mmHg), the risk of AAC is very low.

Possible management by ophthalmologist

AAC: for pupillary block mechanisms, treatment directed to breaking the pupil block and reducing IOP.

Medical 

• systemic agents (e. g. acetazolamide) 
• topical anti hypertensives (e.g. gutt. timolol, gutt. dorzolamide, gutt. brimonidine, gutt pilocarpine).

Urgent interventions 

• argon laser peripheral iridoplasty (occasionally used in advance of YAG LPI when the cornea is cloudy and LPI cannot be performed)
• LPI.

Less urgent interventions

• clear lens/cataract removal.

AAC: for non-pupillary block mechanism with ciliary body oedema (e.g. due to topiramate) YAG LPI and cycloplegics are used instead of pilocarpine.

PAC / PACG: first line treatment options include:

• topical medical therapy
• LPI 
• early (clear) lens extraction in people over 50 years of age (a recent RCT found that clear lens extraction showed greater efficacy and was more cost-effective than LPI).

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup. org)

Sources of evidence

American Academy of Ophthalmology Glaucoma Panel. Preferred Practice Pattern Guidelines: Primary Angle Closure. San Francisco, CA: American Academy of Ophthalmology; 2015

Azuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, Scotland G, Javanbakht M, Cochrane C, Norrie J; EAGLE study group. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016;388(10052):1389-1397

Baskaran M, Kumar RS, Friedman DS, Lu QS, Wong HT, Chew PTK, Lavanya R, Narayanaswamy A, Perera SA, Foster PJ, Aung T. The Singapore Asymptomatic Narrow Angles Laser Iridotomy Study: five-year results of a randomized controlled trial. Ophthalmology. 2022;129(2):147-158

Day AC, Baio G, Gazzard G, Bunce C, Azuara-Blanco A, Munoz B, Friedman DS, Foster PJ. The prevalence of primary angle closure glaucoma in European derived populations: a systematic review. Br J Ophthalmol. 2012;96(9):1162-7

European Glaucoma Society (2020). Terminology and Guidelines for Glaucoma. 5th Edition

He M, Jiang Y, Huang S, Chang DS, Munoz B, Aung T, Foster PJ, Friedman DS. Laser peripheral iridotomy for the prevention of angle closure: a single-centre, randomised controlled trial. Lancet. 2019;393(10181):1609-1618.

Hui X, Michelessi M. Medical interventions for treating primary angle-closure glaucoma. Cochrane Database of Systematic Reviews 2015;12:CD012001

Jindal A, Ctori I, Virgili G, Lucenteforte E, Lawrenson JG. Non-contact tests for identifying people at risk of primary angle closure glaucoma. Cochrane Database of Syst Rev 2020;5: CD012947

Lachkar Y, Bouassida W. Drug-induced acute angle closure glaucoma Curr Opin Ophthalmol 2007;18:129-33

Murray D. Emergency management: angle-closure glaucoma Comm Eye Health. 2018;31/103:64

Napier ML, Azuara-Blanco A. Changing patterns in treatment of angle closure glaucoma. Curr Opin Ophthalmol. 2018;29(2):130-4

NICE Guideline NG81 (2017, updated 2022). Glaucoma: diagnosis and management

Ong AY, Ng SM, Vedula SS, Friedman DS. Lens extraction for chronic angle-closure glaucoma. Cochrane Database Syst Rev. 2021;3(3):CD005555 

Ritch R. The pilocarpine paradox. Journal of Glaucoma. 1996;5:225-7 (no abstract)

Royal College of Ophthalmologists. 2022. Management of angle closure glaucoma guideline.

Sun X, Dai Y, Chen Y, Yu DY, Cringle SJ, Chen J, Kong X, Wang X, Jiang C. Primary angle closure glaucoma: What we know and what we don’t know. Prog Retin Eye Res. 2017;57:26-45

Tanner L, Gazzard G, Nolan WP, Foster PJ. Has the EAGLE landed for the use of clear lens extraction in angle-closure glaucoma? And how should primary angle-closure suspects be treated? Eye (Lond). 2020;34(1):40-50

Wang L, Huang W, Han X, Liao C, Jin L, He M. The Impact of Pharmacological Dilation on Intraocular Pressure in Primary Angle Closure Suspects. Am J Ophthalmol. 2022;235:120-130

Summary

What is Primary Angle Closure / Primary Angle Closure Glaucoma?

The shape of the outer edge of the iris and the drainage channel for the fluid inside the eye (a space known as ‘the angle’) varies from person to person.   This space is normally open, so that the fluid can drain freely, but if the edge of the iris and the drainage channel comes into contact from time to time, the patient is described as a Primary Angle Closure Suspect (PACS). There are no adhesions, there is no rise in eye pressure or evidence that damage to the optic nerve has been caused through raised eye pressure in the past. A condition called Primary Angle Closure (PAC) is present if the eye pressure is raised and/or adhesions between the iris and the drainage channel are present, but there is no damage to the optic nerve (the nerve of sight). If there is damage to the optic nerve caused by rises in eye pressure, the condition is described as Primary Angle Closure Glaucoma (PACG). In this country, this form of glaucoma is rarer than Primary Open Angle Glaucoma (POAG), but it carries a greater risk of damage to vision. This condition affects women more often than men, is commoner in long-sighted people and people of East Asian ancestry, and becomes more likely to occur as people age.  Certain drugs and eye operations can also cause the drainage angle to close.

A sudden complete closure of the angle (known as Acute Angle Closure crisis, AAC), which usually affects just one eye, causes rapidly progressing impairment of vision, redness of the eye, and pain in and around the eye which may be so severe as to cause nausea and vomiting. The eye pressure may be very high, because the fluid continues to be formed within the eye but cannot drain away. Various other changes will be seen in the eye by the examining optometrist.

How is Primary Angle Closure / Primary Angle Closure Glaucoma managed?

An acute attack of angle closure is an emergency which needs same-day referral to the ophthalmologist. There are drugs that the optometrist can use as first aid. The ophthalmologist will also prescribe drugs and may advise laser treatment (‘YAG laser’) to create a tiny hole in the iris (the coloured part of the eye) through which the fluid can drain.  Treatment to the edge of the iris using a different kind of laser (argon laser peripheral iridoplasty) may also be advised. Later, further surgery may be recommended.

If at a routine eye examination there are signs that there have been earlier, milder attacks of angle closure, or if it appears that a patient could develop PACG, the referral can be urgent.

Glaucoma (Primary Angle Closure and Primary Angle Closure Glaucoma) (PAC / PACG)
Version 16
Date of search 15.03.22
Date of revision 14.04.22
Date of publication 27.06.22
Date for review 14.03.24
© College of Optometrists

Angle-closure glaucoma, symptoms, prevention, treatment.

Article updated – 09/27/2019

Without treatment, angle-closure glaucoma will lead to irreversible blindness in 3-5 years. And if an acute attack of glaucoma happens, then you can lose your eyesight in 3 hours, forever! Perhaps we are talking about a diagnosis that you want to understand in more detail. Symptoms, causes, diagnosis and treatment – answers the expert of the Vseozrenii.ru portal.

Contents

• Optic nerve
• Attention! Dangerous sign!
• Subacute attack
• Acute angle-closure glaucoma attack
• What to do in an emergency?
• What should I do now?
• What is angle-closure glaucoma – 5 facts
• Causes of the disease
• Diagnosis
• Treatment

1/10

Optic nerve

Look at the photographs of the fundus taken by an ophthalmologist through the pupil. Inside the eye, the optic nerve works like an electrical cable, transmitting images from the retina to the brain. Normally, the nerve is pale pink, in its center there is a small depression – an excavation, along the edge of which there are vessels.

In angle-closure glaucoma, the optic nerve slowly dies without treatment. In 3-5 years, high eye pressure will make the optic nerve gray and lifeless, like a withered tree, it will stop transmitting signals. The excavation will occupy the entire area and the vessels will move to its edge. The eye will be blinded forever.

This is how vision fades in angle-closure glaucoma from stage to stage. First, small areas of visual field loss appear, then they grow, eating up the entire side view. At the third stage, a person sees, as if through a keyhole – tunnel vision. He does not see a step on the stairs, nor a car on the road, nor pedestrians, exposing himself and those around him to the danger of injury and accidents. At the terminal stage, a residual island or light perception remains from vision. It’s horrible. This should not be allowed, think about it!!!

2/10

Attention! Dangerous sign!

The most insidious symptom of angle-closure glaucoma is the absence of symptoms. A person does not feel any pain or loss of vision until the disease passes into an advanced stage.

3/10

Subacute attack

In the unfavorable course of angle-closure glaucoma, subacute attacks may occur. Only then, due to a sharp increase in pressure in the eye, the patient feels heaviness, dull pain in the eye area, blurred vision and iridescent circles around light sources. A subacute attack either resolves on its own or the condition of the eye deteriorates sharply. You can’t wait for spontaneous recovery – at the first symptoms, immediately consult a doctor!

4/10

Acute attack of angle-closure glaucoma

If you are not lucky, then the subacute attack will develop into an acute one. In this case, a person experiences unbearable pain in the eye, in the head, nausea and vomiting appear, and a sharp loss of vision.

5/10

What to do in an emergency?

If a subacute or acute attack of glaucoma does occur, act immediately! Drop everything and go to an eye clinic or an eye emergency in your city, because an eye can become permanently blind in 3-4 hours. Here is a list of eye clinics in your city.

Eye clinics

6/10

What should I do now?

Fortunately, many of the problems of angle-closure glaucoma can be treated or prevented. There is only one condition – preventive examinations by an ophthalmologist.

If you are over 40 years old and you do not know anything about the risk of developing glaucoma in yourself, take an examination, the doctor will tell you everything.

If you already have a diagnosis of angle-closure glaucoma, have an eye examination at least 2 times a year. Separately, the level of eye pressure should be measured once every 2 months.

Find a qualified doctor, don’t delay diagnosis! Think about yourself, what is it like to be left without sight?!

Eye doctors

7/10

What is angle-closure glaucoma – 5 facts

I will now tell you the most important concepts about angle-closure glaucoma.

First. The structure of the eye. What is this corner and why is it closed? The iris divides the eye into 2 chambers – anterior and posterior. The intraocular fluid flows from the posterior chamber to the anterior chamber and normally leaves the eye through the drainage system at the corner of the anterior chamber. So. If this drainage, located in the corner of the anterior chamber, is blocked by the iris, then there is simply nowhere for the fluid to go, and eye pressure rises. This type of glaucoma is called angle-closure glaucoma.

Second. Angle-closure form – in Europeans it accounts for 6% of all types of glaucoma. It is more common in Asians, people with dark skin color rarely get sick. Third. It affects adults – women 4 times more often than men.
Fourth. More often manifested after 60 years
Fifth. If parents had angle-closure glaucoma, their children have a high risk of developing the disease, since the structure of the eye is inherited.

8/10

Causes of the disease

Let’s discuss what features of the anatomy of the eye predispose to angle-closure glaucoma:

a) The size of the lens of the eye. Increasing with age, the lens shifts the iris anteriorly and creates conditions for closing the angle of the anterior chamber.

b) Corneal diameter. The depth of the anterior chamber is directly related to the diameter of the cornea. In angle-closure glaucoma, this diameter is less than normal.

c) Short eye length – less than 23 mm. As a rule, these are people with hypermetropia, i.e. those who wore plus glasses for distance vision. Their lens is naturally shifted forward and the cornea has a smaller diameter.

9/10

Diagnosis

Unlike open-angle glaucoma, an ophthalmologist can make an accurate diagnosis at the first examination. Having done a gonioscopy – examining the angle of the anterior chamber with a special lens, the doctor will see all the characteristic signs of the disease.

To determine the stage of the disease, the doctor will conduct standard examinations to diagnose glaucoma.

10/10

Treatment

Laser surgery, called “laser iridectomy”, allows you to prevent the threat of an acute attack or cure an acute attack. The point is to create a “window” in the iris, through which the fluid from the posterior chamber flows into the anterior chamber, regardless of the position of the iris and lens.

Eye drops for angle-closure glaucoma perform two functions:

reduce eye pressure

open the angle of the anterior chamber of the eye

Only a doctor can prescribe or cancel drops. Any independent experiments with treatment are prohibited! The task of the patient is to strictly observe the regimen of instillation of drops. According to statistics, 25% of patients do not comply with the regimen, skip or forget about drops, which means they continue to go blind.

Since the disease often manifests itself after 60 years, angle-closure glaucoma is often combined with cataracts. Removing the cataract and installing an artificial lens completely eliminates the problem of closing the angle of the anterior chamber. Sometimes the clear lens is removed to solve the problem. With such a diagnosis, it is important to hear the opinion of an experienced eye surgeon specializing in cataract and glaucoma operations.

If the above methods are not effective or not indicated, then an operation is performed for glaucoma. Surgery for angle-closure glaucoma is a challenging task. Why – read.

Eye medicines

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Primary angle-closure glaucoma

“Glaucoma” is a fairly broad category that combines ophthalmic diseases with specific clinical symptoms. This group includes optic neuropathy, increased IOP and some other diseases.

Contents

Disease classification

Why does it occur

Clinical symptoms

About diagnostic features

Treatment options

How to prevent pathology

If we are talking about primary closed glaucoma, increased intraocular pressure, pupillary block or blockage of the outflow of aqueous humor of the eye can lead to the development of the disease.

Patients over 40 years of age are at risk, and the older the person, the higher the risk of developing pathology. In women, the disease occurs four times more often. Also, the highest prevalence of pathology can be seen among the Eskimos, in China and in the countries of Southeast Asia. Finally, it is worth noting the genetic nature of the inheritance of the pathology, so if the parents had a similar disease, there is a high probability of its development in children, due to the anatomical features of the eye.

But in patients with myopia, the disease is very rare.

Classification of the disease

All the variety of pathologies that have signs of angle-closure glaucoma can be divided into several groups, depending on the selected distinguishing feature:

1. Anterior chamber angle (AC) blocking mechanism. This feature divides the pathology into groups with pupillary block, with a short PC angle, with a flat iris, with vitreo-lens block.
2. Stages of pathology. There is a first stage, which is called early. This is followed by the second stage, it is also developed. The third stage is called advanced. And, finally, the terminal stage – respectively, the fourth.
3. Clinical course of the disease. Glaucoma can be asymptomatic, then we are talking about a latent pathology. Ophthalmologists also distinguish subacute and acute attacks, chronic form.

Why does it occur

Various factors can lead to the development of pathology. Including certain genetic ones: structural features of the eye, the functioning of the endocrine system, age-related changes in the ophthalmic eye drainage system, the state of the nervous system, and the nuances of metabolism.

Anatomical causes can also contribute to the development of the disease, for example, a reduced PC, an increased size of the lens, which provokes its displacement to the cornea, a shortened intraocular axis.

Elevated IOP in the posterior chamber can also lead to the development of glaucoma. The pressure itself can increase due to various factors. For example, if the iris presses on the trabecular tissue, anterior synechiae occur, IOP rises – this contributes to the development of “creeping” glaucoma. Or we can talk about a gradual blocking of the angle of the PC of the iris, as a result of which the outflow of moisture from the PC is disturbed, IOP increases, the iris becomes flat, and pathology occurs.

Clinical symptoms

Blocked pupil glaucoma is one of the most common pathologies. 8 out of 10 glaucoma diagnoses are due to this form of pathology, and it occurs mainly in women.

The disease with pupillary block is characterized by paroxysmal course, while in the latent period it is asymptomatic. It is possible to detect a slight displacement of the iris and shallowing of the anterior eye chamber only when conducting a biomicroscopic examination.

With this form of pathology, IOP does not increase. The latent period is characterized by a chronic type of angle closure. In most cases, the pathology manifests itself in the form of a subacute or acute attack.

A subacute attack does not have clear and pronounced clinical symptoms. Patients often note the loss of a lobe of the visual field, multi-colored halos from light objects, which indicates corneal edema. Sometimes there is a feeling of discomfort in the eye area, the pupil may dilate slightly, IOP may increase slightly, and the head may hurt. The corner of the PC is partially closed.

As for an acute attack, it proceeds in cycles, includes five phases:

1. Starting. The root of the iris overlaps the angle of the PC, which provokes bombardment of the iris.
2. Compression. The bombardment becomes more and more pronounced, the outflow of fluid from the PC is no longer possible, moisture flows to the Schlemm’s canal, IOP rises significantly and rapidly, vision is rapidly falling, and severe pain develops in the eye area.
3. Reactive. It is characterized by an increase in symptoms. Vascular permeability increases, the iris swells, moisture in the PC becomes cloudy due to an increase in the amount of protein. IOP rises significantly, the veins dilate, the optic nerve head (OND) swells.
4. Strangulation. At this stage, blood circulation is already disturbed, an inflammatory process begins, which can degenerate into necrosis. In parallel, the iris atrophies, the pupil expands, stops responding.
5. Reverse development. The production of moisture in the PC is significantly reduced. IOP decreases, bombardment of the iris weakens, the angle of the PC opens slightly. After an attack, some symptoms remain forever – for example, pupil deformity.

If we are talking about a pathology with relative blockage of the pupil, we note that the disease proceeds in a chronic form. Glaucoma develops due to repeated attacks. With a consistently elevated IOP, this form of pathology proceeds similarly to open-angle glaucoma.

Quite rarely (about 10% of cases of the total number of glaucoma diagnoses) there is a “creeping” form with a reduced angle. Women are at risk. It is characterized by frequent separation of the iris from the trabeculae. As a result, goniosynechia of various heights are formed, and the iris “crawls” onto the trabecula. “Crawling” glaucoma is characterized by a chronic course, interrupted by subacute attacks. If therapy is not carried out in time, the optic disc may become deformed, which will lead to the loss of some visual fields.

Pathology with a flat iris is characterized by the following symptoms: PC has an optimal depth, the angle is closed, there is no bombardment of the iris. This form of pathology is more common in young patients. An acute attack develops against the background of a dilated pupil, so that the root of the iris overlaps the AUC. In the treatment of this type of pathology, it makes no sense to do iridectomy due to its inefficiency, and miotics provide a good hypotensive effect.

Finally, a malignant pathology accompanied by a vitreous lens block is diagnosed infrequently, but it is characterized by a very severe course. Accompanied by pupillary block, closed PC angle, increased IOP.

About diagnostic features

It all starts with taking an anamnesis. This stage is extremely important, since the disease is characterized by an undulating course, and between attacks it can be asymptomatic. In this case, glaucoma often occurs in both eyes, while attacks can be observed alternately.

Usually, as a result of anamnesis, stress, hypothermia are determined as the cause of the attack. Sometimes provoking an attack can be a long stay in a pose with your head tilted down.

Physical examinations include external examination, perimetry and visometry, and biomicroscopy to determine the condition of the eye structures. Instrumental studies are carried out – ophthalmoscopy, gonioscopy, biometric procedures using ultrasound.

Each form of pathology is accompanied by characteristic symptoms:

1. With blocked pupil. Pathology is asymptomatic. Slight blurred vision, discomfort in the eye area, multi-colored halos around light sources indicate a subacute attack, sometimes patients indicate pain in the area above the eyebrows. Gonioscopy reveals blockade of the PC angle. During tonometry, a significant increase in IOP is diagnosed. As for the diagnosis of an acute attack, then difficulties are extremely rare. Patients talk about pain in the eyebrows and eyes, indicate a sharp and pronounced deterioration in vision. During an ophthalmological examination, the doctor may detect a congestive injection, edematous conjunctiva, the cornea also swells, becomes opaque. PC can often be found only in the pupillary area, so pronounced it loses depth. The pupil acquires a curved shape, greatly expands.
2. Creeping. It runs unsystematically. The nuances of gonioscopic examination are expressed in the replacement of the apex of the angle with the root of the iris from the ciliary body.
3. With vitreocrystalline block. It is not easy to diagnose, but making a diagnosis is very important. During the examination, symptoms such as a small PC with a closed angle, increased IOP, relative block of the pupil can be detected. In most cases, the pathology is diagnosed by chance.
4. Flat iris. The course of the pathology is characterized by a closed angle of the PC and a flat attachment of the iris, which leads to shallowing of the PC in the periphery zone, while in the center one can see the relative depth.
5. After glaucoma surgery. A pathology that is malignant in nature, and among the symptoms of which one can single out a small PC, the absence of filtration along the outflow trajectory. Biomicroscopy makes it possible to identify free areas in the ST. Ultrasound makes the diagnosis more accurate.

Treatment options

If malignant glaucoma is diagnosed, an acute attack is diagnosed, or IOP cannot be reduced, the patient must be hospitalized.

You can help yourself with an acute attack on your own – take a hot foot bath, take a laxative on a salt basis, put a mustard plaster on the back of your head. Please note that these actions should be considered only as first aid, but certainly not as a substitute for a full-fledged treatment.

In the chronic course of the pathology, drug treatment is suggested. To stop an acute attack, local beta-blockers are used. Therapy of a malignant form involves the appointment of drugs of local action.

If the patient has previously been diagnosed with an attack, either subacute or acute, the other eye is also treated with laser iridectomy for prophylactic purposes. If the pathology is latent, the operation is performed on two eyes to prevent seizures. However, in two cases out of ten, this measure will be ineffective.

If drug treatment and laser techniques do not stop the attack, reduce IOP, surgical treatment is performed. A sinustrabeculectomy is scheduled. At the initial stage, they can drain the posterior eye chamber according to Takhchidi or perform iridocycloretraction according to Krasnov.

Treatment of postoperative glaucoma involves several variations – it can be laser vitrolysis, eye lens extraction, or a combination.

After treatment, patients are observed in the dispensary in dynamics, where the effectiveness of therapy, the course of the disease are strictly controlled, and irreversible changes are prevented.

How to prevent pathology

To prevent the occurrence of acute attacks, you need to follow certain recommendations:

• refuse to visit saunas and baths;
• avoid stress;
• do not stay in an inclined position for a long time, as well as in a position with your head tilted down;
• do not remain for a long time without light with your eyes open;
• avoid hypothermia and sudden changes in temperature;
• give up sports and excessive physical activity;
• do not drink too much liquid;
• give up bad habits (tobacco, alcohol).

Timely diagnosis and competent therapy allow counting on a favorable prognosis, especially when it comes to latent or chronic pathology. If attacks occur, the favorable prognosis is called into question, since each new attack leads to the rapid progression of the disease. The most difficult case is malignant glaucoma, it is difficult to count on a good prognosis here.