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Management of Angle Closure Glaucoma
Hospital Authority Convention
18 May 2015
Jimmy Lai
Clinical Professor
Department of Ophthalmology
The University of Hong Kong
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Primary Angle Closure Glaucoma PACG
• Optic neuropathy 2o to increased IOP caused by angle closure
• Result of apposition/adhesion (PAS) of peripheral iris to trabeculum
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Gonioscopy
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Drainage angle
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Sclera
Lens
Trabecular
meshwork
Cornea
Iris
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Gonioscopy
Open angle Narrow angle
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Ophthalmic ultrasound imaging
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Ophthalmic ultrasound imaging
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Terminology
1. Primary angle closure suspect (PACS)
– 180 degree TM not visualized
2. Primary angle closure (PAC)
– PACS + IOP>21mmHg
3. Primary angle closure glaucoma (PACG)
– PAC + optic neuropathy
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Natural course of PACG
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The Singapore Chinese Eye Study • 2009-2011
• 3353 Chinese > 40years
• Prevalence:
– Glaucoma - 3.2%
– POAG - 1.4%
– PACG - 1.2% (*PACG only, PACS and PAC not included)
– Secondary glaucoma
• Prevalence of blindness:
– Secondary glaucoma 14.3%
– PACG 10.2%
– POAG 8.8%
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Mechanisms of angle closure
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Mis-direction
of aqueous
Phacomorphic Plateau
iris
Pupil block
1.Plateau iris
2.Pupillary block
3.Phacomorphic
4.Aqueous misdirection
5.Mixed
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Primary Angle Closure Glaucoma
• Angle closure risk factors:
– Short axial length
– Shallow AC
– Thick lens
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Relative lens vault
Scleral spur Scleral spur
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Lens
vault
Lens thickness
Cornea
Anterior vault
Relative LV = LV/AV
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Angle closure mechanisms
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PACG
• Acute and chronic subtypes
• Acute primary angle closure
– Symptomatic
– Results from sudden appositional angle closure leading to a very high IOP
• Chronic angle-closure glaucoma
– More insidious
– May follow acute PAC or arise de novo
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Corneal edema,
Fixed pupil
Ciliary flush
IOP>40mmHg
vision
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Treatment of PACG
– Decrease IOP
– Reduce risk of further ON damage
– Stop progressive angle closure
– Abolish risk of acute angle closure
– Open up closed angle
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Treatment of PACG
Two-step approach
• 1) IOP reduction to relieve symptoms & to prevent
irreversible optic nerve damage
– By systemic & topical IOP-lowering medications or ALPI
• 2) Relieve angle closure mechanism(s) to prevent
recurrence
– By LPI
Anterior segment/drainage angle reconstruction
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Phacoemulsification in Angle Closure Glaucoma
• Angle closure mechanisms - racial difference
• Mixed type more common in Asian, pure pupillary block more
common in Western population
• LPI not as effective as expected in Asian than in Caucasian
• A significant proportion of patients progressed to chronic type
of PACG after LPI
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Treatment of PACG
• 2-step approach effective in majority of PACG
• Phacoemulsification becoming more popular in the 2nd step
– It is claimed that by removing the lens or cataract, angle
closure factors other than the pupillary block are also
eliminated
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Phacoemulsification + intraocular lens implant
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Effect of cataract extraction on angle structure
• Angle widen
• AC deepen
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Effect of cataract extraction on IOP
Before
phacoemulsification
At final FU
(Mean FU = 18.0 ± 2.9
months)
P value (paired t test) (Preoperative values vs values at final FU)
IOP 19.7 ± 6.1 mm Hg
15.5 ± 3.9 mm Hg
0.022
Number of topical
glaucoma drugs
1.91 ± 0.77
0.52 ± 0.87
< 0.001
J Glaucoma 2006 22
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Non-visually significant cataract extraction in PACG
Against For
Removal of a normal ocular structure May be normal functionally but not anatomically
Effectiveness not proven Extrapolate results from cataract extraction/PACG Case reports, non-RCT case series
Surgical risks Minimal
Lack of outcome predictor ?phaco/PACG, GSL/PACG
Limited choices of IOL May correct pre-existing refractive errors
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EAGLE study Effectiveness, in Angle-closure Glaucoma, of Lens Extraction
• Multi-center RCT
• Around 400 subjects
• Evaluate whether early lens extraction improves
clinical outcomes & cost-effectiveness compared
with LPI
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Angle Closure Glaucoma Consider phacoemulsification
• Visually significant cataract
• Shallow AC after LPI
• Uncontrolled IOP/progressive angle closure after LPI
• Clinically bulging lens (increased relative lens vault)
• Hypermetropia >+2D & both eyes indicated for lens extraction
• Loose zonules
• Age>50
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Management of PACG
Medical therapy
Phaco
Early cataract/Lens extraction
Newly diagnosed PACG
Acute, chronic
Cataract, no cataract
IOP controlled IOP uncontrolled
LPI
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What if phacoemulsification fails to control IOP
• Goniosynechyliasis (GSL)
• Glaucoma filtration surgery
– Trabeculectomy
– Glaucoma shunt
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Cost-effectiveness of phacoemulsification in the treatment of PACG
Local data from 3 HA hospitals from March 2002 to October 2007
• 53 PACG eyes with phacoemulsification:
• Before surgery
– Mean IOP 19.8 +/- 6.1 mmHg
– Mean number of glaucoma drugs 2.7 +/- 1.0
• At 6 years
– Mean IOP 14.7 +/- 2.5 mmHg
– Mean number of glaucoma drugs 1.6 +/- 1.2
• 10 patients (18.9%) required trabeculectomy at a mean time of 2.53 +/-
1.38 years 28
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Summary
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• Primary angle closure is an anatomical disorder (occludable angle)
• Can progress from PACS to PAC & to PACG
• Anatomical disorder may be reversed but not the optic nerve damage
• 2-step treatment approach to PACG relatively clear cut
• Treatment of PACS and PAC controversial
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Summary
• PACG can be acute or chronic (majority)
• Treatment is by 2-step approach
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Acute Chronic
1st step IOP reduction
In hours In weeks
2nd step Anterior segment reconstruction
LPI in hours to days Cataract extraction when
indicated
Cataract extraction when indicated
3rd step Glaucoma surgery
When 2-step approach fails When 2-step approach fails
Loss of vision if untreated Immediate Gradual
Follow-up Life long Life long
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Management of Angle Closure Glaucoma
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Thanks to the human lens which after removal, leaves more
space inside the eye which is desperately needed in PACG
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Thank you
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