24A. Closed angle glaucoma
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What is angle closure glaucoma?
- mecahnical obstruciton of TM: pupil block, anterior pulling/push
- obstructs outflow
2 types of angle closure?
- pupil block: aqueous flowing form post to ant chamb pushes on peripheral iris forward->blocks trab meshwork
- peripheral anterior synechiae
How can indentation gonio differentiate between pupil block and synechiae?
- pupil block: indentation will relieve closure by pushing aqueous to the periphery and open the angle
- synechiae: will see it, angle will not open
Fellow eye with ACG?
- no symptoms
- 180-270 degree
- PACS with ^IOP
- no disc/VF changes
optic neuropathy and VF loss
sx of acute congestive closure?
Appearance of acute congestive closure?
- ciliary injection
- corneal edema
- dilate fixed vert elongated pupil
Signs of acute congestive closure?
- shallow AC
- shaffer grade 0
- IOP 50-80mmHg
Management of acute attack
- EMERGENCY: same day referral
- lower IOP/break attack
- VA loss 24-36 hrs
- lie px supine
- CAI inhibitor, miotics, steroids
- corneal indentation (not synechiae
Laser peripheral iridotomy
- laser holes in the iris
- prophylactic fellow eye
- helps iris move backwards
- reduces narrow angle
- remove a wedge of peripheral iris to increase outflow
- slow porgressive ACG
- misdiagnosis: OAG
Plateau iris syndrome?
- thicking peripheral iris/anterior insertion of iris
- dilate with caution
- laser is aimed at the junction of pig/non pic TM
- burns are applied
- if aimed too post/ant wont work and damage will occur
selectively targets pigmented cells with little or no damage to surrounding structres
Level of effectiveness of laser trabeculoplasty?
- 25-30% reduction in IOP
- loses effect over ~5yrs
ALT and SLT predictor success?
- TM pigmentation: PDS, PXF, POAG
- cut a flap in peripheral conjunctiva so aqueous can drain into sub tenon's space
- filtration bleb
- surgery to deal with refractory glaucoma
- implants have long tube-> AC-> drain into episclearl plate-> acts as a bleb spreading device
- surgical and laser procedures that ablate the ciliary body to lower iop
- lasr resort
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