Canadian Ophthalmological
Society
Evidence-based Clinical Practice
Guidelines for the Management of
Glaucoma in the Adult Eye
Angle-closure Glaucomas
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 subclassification 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 2009;44(Suppl 1):S1S93.
Angle-closure glaucomas
• Patients with PACG commonly present with
1 of 3 possible scenarios:
– acute angle closure,
– narrow angle at risk of acute closure with normal
IOP, 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 2009;44(Suppl 1):S1S93.
Classification of angle closure
based on functional cause
Pupil
Primary
Pupil block Primary acute
or chronic
angle closure
Non-pupil
block
Plateau iris
syndrome
Examples of secondary
•
•
•
•
•
Posterior synechiae
Silicone oil
AC IOL without iridectomy
Lens subluxation or lens swelling
Posterior mechanisms
− Choroidal tumour
− Choroidal effusion
o medication-induced (sulfonamides)
o spontaneous
− Ciliary block
− Lens-induced
• Anterior mechanism
− Angle neovascularization
− Iritis
− ICE syndrome
− Epithelial down growth
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Risk factors for development of
primary angle closure
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•
•
•
•
•
•
•
•
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 2009;44(Suppl 1):S1S93.
Acute angle closure:
Signs and symptoms
Symptoms include:
Signs include:
•
•
•
•
•
•
•
•
•
•
•
•
•
Severe pain
Headache
Nausea and vomiting
Blurred vision
Halos around lights
Conjunctival injection
Ciliary flush
Corneal edema
Fixed mid-dilated pupil
Shallow anterior chamber
Elevated IOP
Sometimes glaukomflecken
The angle is observed to be closed
on gonioscopic examination
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
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 2009;44(Suppl 1):S1S93.
Narrow angle at risk of closure
(angle-closure suspect) (cont’d)
• 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 2009;44(Suppl 1):S1S93.
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 2009;44(Suppl 1):S1S93.
Diagnosis of
Angle Closure Glaucomas
Diagnosis of
angle 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:
o
o
o
o
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 previous
intermittent attacks of angle closure.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Diagnosis of
angle 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 2009;44(Suppl 1):S1S93.
Diagnosis of
angle 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 2009;44(Suppl 1):S1S93.
Gonioscopy technique in
narrow 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 2009;44(Suppl 1):S1S93.
Treatment of
Angle-Closure Glaucomas
Treatment of
angle-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 2009;44(Suppl 1):S1S93.
Treatment of primary acute
angle 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 2009;44(Suppl 1):S1S93.
Treatment of primary acute
angle closure (cont’d)
• 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 4mirror 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 2009;44(Suppl 1):S1S93.
1. Anderson DR. Am J Ophthalmol 1979;88:1091–3.
Treatment of primary acute
angle closure (cont’d)
• 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 2002;11:484–7.
2. Lam DSC, et al. Ophthalmology 2002;109:64–70.
Canadian Ophthalmological Society evidence-based clinical
3. Greve EL. Int Ophthalmol 1988;12:157–62.
4. Schwartz GF, et al. Ophthalmic Surg 1992;23:108–12. practice guidelines for the management of glaucoma in the
5. Ang LP, et al. Ophthalmology 2000;107:2092–6.
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Treatment of narrow angle
with 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.
1. Ang LP, et al. Ophthalmology 2000;107:2092–6.
2. Friedman DS, et al. Ophthalmology
2006;113:1087–91.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Laser iridotomy — prophylaxis
against 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].
1. Ang LP, et al. Ophthalmology 2000;107:2092–6.
2. Friedman DS, et al. Ophthalmology
2006;113:1087–91.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Treatment of
chronic 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 2009;44(Suppl 1):S1S93.
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 2009;44(Suppl 1):S1S93.
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 2009;44(Suppl 1):S1S93.
Neovascular Glaucoma
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 retinal
vein 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 2009;44(Suppl 1):S1S93.
Treatment of
neovascular 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 openangle glaucoma.
• If there is significant visual potential, filtering surgery
is often required.
• If there is minimal visual potential, cycloablation is
useful.1
1. Iliev ME, et al. Br J Ophthalmol 2007;91:1631–5.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Ciliary Block Glaucoma
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 2009;44(Suppl 1):S1S93.
Treatment of
ciliary 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
1. Chandler PA, et al. Am J Ophthalmol
1968;66:2495–502.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
Treatment of ciliary block
glaucoma (cont’d)
• If the attack cannot be broken:
– in phakic eyes:
• a vitrectomy is indicated
– in pseudophakic or aphakic eyes:
• an attempt at Nd:YAG laser lysis of the anterior
hyaloid and posterior capsule (hyaloidotomy or
vitreolysis) may avoid a vitrectomy1
1. Epstein DL, et al. Am J Ophthalmol
1984;98:137–43.
Canadian Ophthalmological Society evidence-based clinical
practice guidelines for the management of glaucoma in the
adult eye. Can J Ophthalmol 2009;44(Suppl 1):S1S93.
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 2009;44(Suppl 1):S1S93.