Ophthalmology 2006;113:1087 91. * Glaucoma slides - July 2

1
Canadian Ophthalmological Society

• Evidence-based Clinical Practice Guidelines for
  the Management of Glaucoma in the Adult Eye

2
Angle-closure Glaucomas
3
Angle-closure glaucomas

• The most useful classification for angle-closure
  glaucoma is based upon etiology.
• The most important criterion is the presence or
  absence of pupil block, with further
  sub-classification into primary and secondary
  mechanisms.
• The prevalence of PACG varies significantly among
  different ethnic groups.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
4
Angle-closure glaucomas

• Patients with PACG commonly present with1 of 3
  possible scenarios
• acute angle closure,
• narrow angle at risk of acute closure with
  normalIOP, or
• creeping angle closure with or without elevated
  IOP.
• Patients may present with what appears to be
  chronic OAG, but angle closure is subsequently
  discovered on gonioscopy.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
5
Classification of angle closurebased on
functional cause
Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
6
Risk factors for development ofprimary angle
closure

• Axial hyperopia
• Family history of angle closure
• Advancing age
• Female gender
• East Asian ethnicity
• Inuit ethnicity
• Latino ethnicity
• Shallow peripheral anterior chamber
• Short axial length eyes

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
7
Acute angle closure Signs and symptoms
Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
8
Narrow angle at risk of closure(angle-closure
suspect)

• A patient would be considered an angle-closure
  suspect if he or she had iridotrabecular contact
  on gonioscopy without PAS, and without GON and VF
  damage.
• There are usually no symptoms associated with a
  narrow angle however, intermittent angle closure
  is possible.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
9
Narrow angle at risk of closure(angle-closure
suspect) (contd)

• Signs of narrow angle at risk of closure include
• Shallow peripheral anterior chamber and an open
  angle on gonioscopy.
• Trabecular meshwork, while still visible, is
  almost or partially occluded.
• The IOP is not elevated.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
10
Creeping angle closure

• There are no symptoms associated with creeping
  angle closure.
• Signs include
• normal or elevated IOP,
• PAS in portions of the angle,
• possible optic disc damage, and
• possible glaucomatous VF defects.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
11
Diagnosis ofAngle Closure Glaucomas
12
Diagnosis ofangle closure glaucoma

• Diagnosis requires a detailed history and
  physical exam.
• History must include
• whether the pupil has ever been pharmacologically
  dilated,
• medication history to elicit the use of
  medications that may dilate the pupil, such as
  those
• with anticholinergic effects/side effects
• that counteract the iris sphincter muscle
• with sympathomimetic effects that work on the
  iris dilator muscle,
• that may cause anterior movement of the lens iris
  diaphragm (e.g., sulfonamides)
• family history of acute glaucoma or previous
  laser iridotomy in a first-degree relative, and
• personal history indicative of symptoms of
  previousintermittent attacks of angle closure.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
13
Diagnosis ofangle closure glaucoma

• On examination, it is important to note
• visual acuity
• refractive error
• pupil size and reaction
• presence of corneal edema
• anterior chamber depth centrally and peripherally
• presence of iris or angle new vessels indicative
  of neovascularization
• presence of anterior chamber inflammation
• IOP
• lens appearance

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
14
Diagnosis ofangle closure glaucoma

• Gonioscopy of both eyes is mandatory to assess
  the depth of the anterior chamber and the
  presence of PAS (compression gonioscopy with a
  Zeiss-type lens is very useful in differentiating
  PAS from apposition).

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
15
Gonioscopy technique innarrow angles

• Recommendation
• Careful gonioscopy, performed under ideal
  conditions (dim ambient light, narrow light beam
  from the slit lamp, use of compression
  gonioscopy) is fundamental to assess the presence
  of angle closure in patients suspected of having
  narrow angles Consensus.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
16
Treatment of Angle-Closure Glaucomas
17
Treatment ofangle-closure glaucoma

• Treatment should be based on the type and cause
  of the angle closure, i.e.
• primary acute angle closure,
• narrow angle with normal IOP,
• chronic angle closure, or
• secondary angle closure (which will further
  depend upon the particular underlying mechanism).

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
18
Treatment of primary acuteangle closure

• Upon diagnosis, agents to lower IOP are
  indicated, including
• topical beta blockers
• topical miotics
• topical alpha-2 adrenergic agents
• topical and (or) systemic carbonic anhydrase
  inhibitors
• prostaglandins
• systemic hyperosmotics

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
19
Treatment of primary acuteangle closure (contd)

• Topical glycerol 100 (to achieve temporary
  clearing of the cornea when edema is present) may
  be useful.
• Corneal indentation (Anderson manoeuvre)1 with
  the tip of the Goldmann tonometer or Zeiss
  4-mirror lens may be useful.
• Laser iridotomy should be performed when the
  cornea is clear.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.

• Anderson DR. Am J Ophthalmol 19798810913.

20
Treatment of primary acuteangle closure (contd)

• In some instances, when the acute attack cannot
  be broken, peripheral laser iridoplasty may be
  helpful.1
• In some instances, anterior chamber
  paracentesis,2 lens extraction,3 or surgical
  iridectomy4 may be useful.
• Laser iridotomy to the fellow eye is indicated to
  prevent an attack in the fellow eye (if it is
  similarly predisposed).5

1. Lai JSM, et al. J Glaucoma 2002114847. 2.
Lam DSC, et al. Ophthalmology 20021096470. 3.
Greve EL. Int Ophthalmol 19881215762. 4.
Schwartz GF, et al. Ophthalmic Surg
19922310812. 5. Ang LP, et al. Ophthalmology
200010720926.
Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
21
Treatment of narrow anglewith normal IOP

• Laser iridotomy is effective as a preventive
  measure in patients at moderate to high risk of
  experiencing an angle closure attack.1,2
• An occludable angle would include
• those with any degree of appositional closure, or
• when more than 180 of trabecular meshwork cannot
  be visualized with proper gonioscopic maneuvers.
• When the trabecular meshwork can be visualized
  for 360, but the approach is very narrow and
  therefore felt to be at risk for closure,
  consideration should also be given to performing
  an iridotomy.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
1. Ang LP, et al. Ophthalmology 200010720926.
2. Friedman DS, et al. Ophthalmology
2006113108791.
22
Laser iridotomy prophylaxisagainst acute angle
closure

• Recommendation
• Laser peripheral iridotomy should be performed in
  patients with narrow angles at risk for an attack
  of acute angle closure Level 1B1,2.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
1. Ang LP, et al. Ophthalmology 200010720926.
2. Friedman DS, et al. Ophthalmology
2006113108791.
23
Treatment ofchronic angle closure

• Angle closure becomes chronic when permanent PAS
  develop.
• Once the pupil block component has been resolved
  by laser iridotomy, the IOP control is achieved
  by the same protocol as with chronic open-angle
  glaucoma.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
24
Treatment of secondary angle closure

• Treatment is aimed at the specific etiology,
  e.g.
• In lens-induced mechanisms, lensectomy may be
  indicated.
• In neovascularization, intravitreal anti-VEGF
  medication may help cause regression of the
  fibrovascular membrane.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
25
Laser iridotomy suspected pupillary block

• Recommendation
• Laser peripheral iridotomy should almost always
  be considered to remove the pupil block component
  in angle closure. It is even indicated in
  suspected cases of angle closure due to posterior
  mechanisms or plateau iris appearance in order to
  eliminate any possible pupillary block component.
  It is not indicated in cases secondary to
  anterior mechanisms such as angle
  neovascularization, iritis with PAS,
  iridocorneal-endothelial syndrome or epithelial
  down growth, as pupil block is not typically a
  factor in these situations Consensus.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
26
Neovascular Glaucoma
27
Neovascular glaucoma

• Neovascular glaucoma is a common form of
  secondary non-pupil block anterior-mechanism
  glaucoma.
• The most common inciting factors are
• posterior segment ischemia due to central
  retinalvein occlusion, or
• diabetes mellitus.
• These lead to anterior segment iris and angle new
  vessel formation.
• The angle new vessels form a fibrovascular
  membrane, which contracts to create PAS and angle
  closure.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
28
Treatment ofneovascular glaucoma

• Treatment is aimed at controlling the cause of
  the new vessels
• by PRP, and
• possibly intraocular injection of anti-VEGF
  medication.
• IOP is controlled by the usual protocol as for
  open-angle glaucoma.
• If there is significant visual potential,
  filtering surgery is often required.
• If there is minimal visual potential,
  cycloablation is useful.1

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
1. Iliev ME, et al. Br J Ophthalmol
20079116315.
29
Ciliary Block Glaucoma
30
Ciliary block glaucoma

• Ciliary block glaucoma (malignant glaucoma or
  aqueous misdirection) is a rare cause of
  secondary non-pupil block posterior-mechanism
  glaucoma.
• It may occur after intraocular surgery of any
  kind, and may even occur after a laser iridotomy.
• It is likely due to ciliary body rotation and
  aqueous misdirection posteriorly.
• It may occur in phakic, pseudophakic or aphakic
  eyes.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
31
Treatment ofciliary block glaucoma

• Initial treatment includes
• laser iridotomy to minimize any potential pupil
  block component, as well as
• maximal cycloplegia with atropine.1
• Acute treatment includes
• topical beta blockers
• topical and (or) systemic carbonic anhydrase
  inhibitors
• prostaglandins, alpha-2 adrenergic agents
• systemic hyperosmotics

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
1. Chandler PA, et al. Am J Ophthalmol
1968662495502.
32
Treatment of ciliary blockglaucoma (contd)

• If the attack cannot be broken
• in phakic eyes
• a vitrectomy is indicated
• in pseudophakic or aphakic eyes
• an attempt at NdYAG laser lysis of the anterior
  hyaloid and posterior capsule (hyaloidotomy or
  vitreolysis) may avoid a vitrectomy1

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.
1. Epstein DL, et al. Am J Ophthalmol
19849813743.
33
Aqueous misdirection syndrome

• Recommendation
• Ciliary block (aqueous misdirection syndrome)
  must be considered in any patient with
  postoperative shallow anterior chamber with
  elevated or normal IOP Consensus.

Canadian Ophthalmological Society evidence-based
clinical practice guidelines for the management
of glaucoma in the adult eye. Can J Ophthalmol
200944(Suppl 1)S1?S93.