C. Nucci et al. (Eds.

)
Progress in Brain Research, Vol. 173
ISSN 0079-6123
Copyright r 2008 Elsevier B.V. All rights reserved

CHAPTER 4

Angle-closure: risk factors, diagnosis and treatment

Nishani Amerasinghe and Tin Aung

Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, Singapore

Abstract: Introduction: Primary angle-closure glaucoma (PACG) is the leading cause of blindness in East
Asia. The disease can be classied into primary angle-closure suspect, primary angle closure (PAC), and
PACG. Pupil-block, anterior nonpupil-block (plateau iris and peripheral iris crowding), lens related and
retrolenticular mechanisms have been suggested as the four main mechanisms of angle closure. Risk
factors: The risk factors for PAC are female gender, increasing age, Inuit or East Asian ethnicity, shallow
anterior chamber, shorter axial length, and genetic factors. Diagnosis: The diagnosis of acute PAC is
mainly clinical. Diagnosis can be made with careful slit lamp examination, including intraocular pressure
(IOP) measurement and gonioscopy. The diagnosis of chronic PAC and chronic PACG also require a
careful history to assess risk factors, slit lamp examination including IOP and gonioscopy. Further
investigations may also be required including visual elds, ultrasound biomicroscopy, and other imaging
methods. Management: In acute PAC, rapid control of the IOP needs to be achieved to limit optic-nerve
damage. This can be carried out medically, and/or by laser iridoplasty. Both the affected and fellow eye
should undergo laser peripheral iridotomy (PI). The aim of treating chronic PAC is to eliminate the
underlying pathophysiological mechanism and to reduce IOP. This can be done by carrying out laser PI,
iridoplasty, medical therapy, or surgery (trabeculectomy, lens extraction, combined lens extraction with
trabeculectomy and goniosynechialysis). Conclusion: Angle-closure glaucoma is usually an aggressive,
visually destructive disease. By assessing the risk factors and diagnosing the mechanism involved in a
patients condition, the management of that patient can be tailored appropriately.

Keywords: primary angle-closure suspect; primary angle closure; primary angle-closure glaucoma; risk
factors; diagnosis; management

Introduction responsible for over 90% of bilateral glaucoma

Primary angle-closure glaucoma (PACG) is a
leading cause of blindness in East Asia (Foster
et al., 1996, 2000; Foster and Johnson, 2001). It
has a greater tendency to cause bilateral blindness
than primary open angle glaucoma (POAG) (Seah
et al., 1997; Wong et al., 2000). In China, PACG is
Corresponding author. Tel.: (65) 6322 4592;
Fax: (65) 6322 4598; E-mail: tin11@pacic.net.sg
blindness (Foster and Johnson, 2001). It is also
responsible for most bilateral glaucoma blindness
in Singapore and India (Dandona et al., 2000;
Foster et al., 2000).
Due to the problem of variability of nomencla-
ture for angle closure in early papers, recent studies
have adopted the following denitions. Primary
angle-closure suspect (PACS) is the term for an eye
in which contact between the peripheral iris and
posterior trabecular meshwork is considered possi-
ble, but there are no other abnormalities in the eye

DOI: 10.1016/S0079-6123(08)01104-7 31
32

(Aung et al., 2001; Foster et al., 2002). Primary
angle closure (PAC) is present when there are
features indicating that trabecular meshwork
obstruction by the peripheral iris has occurred with
consequences in the eye such as peripheral anterior
synechiae (PAS), increased intraocular pressure
(IOP), iris whorling, glaucomeken, lens opacities,
or excessive pigment deposition on the trabecular
meshwork. At this stage, the optic disc does not
have signs of glaucomatous damage. PACG is PAC
with evidence of glaucomatous optic neuropathy
(GON). Table 1 summarizes the denitions.
A patient with acute primary angle closure
(APAC) usually has the following symptoms:
ocular or periocular pain, nausea and/or vomiting,
a history of intermittent blurring of vision with
haloes, IOP W 21 mmHg: and the following signs:
conjunctival injection, corneal epithelial edema,
mid-dilated unreactive pupil, shallow anterior
chamber, and the presence of an occludable angle.
Mechanism
The mechanism responsible for angle closure is also
important, especially in planning clinical manage-
ment. Pupil-block, anterior nonpupil-block (plateau
iris and peripheral iris crowding), lens related and
retrolenticular mechanisms have been suggested as
the four main mechanisms of angle closure, though
they may coexist. When assessing a case of angle
closure both staging and mechanism should be
taken into account (Ritch and Lowe, 1996a).
Ritch et al. described the mechanisms of angle
closure resulting in iris blocking aqueous outow
through the trabecular meshwork. This is caused
by forces acting at four anatomic levels: the iris,
ciliary body, the lens, and vectors posterior to the
lens. It should be noted that each level of the block
may have a component of the preceding levels and
a combination of mechanisms may coexist in the
same patient. Therefore, treatment can become
more complex for each level of the block as the
lower levels of block may also require treatment
(Ritch and Lowe, 1996a).
Level 1 iris and pupil
Pupillary block is the most common mechanism
of angle closure (Nolan et al., 2000), the majority of
other causes of angle closure will have an element of
pupil block. In East Asians, the mechanism is
predominantly mixed (He et al., 2006). In pupillary
block, there is resistance to aqueous ow through
the pupil in the area of iridolenticular contact. This
causes a limitation of aqueous ow from the
nonpigmented ciliary epithelium (where it is pro-
duced) in the posterior chamber to the anterior
chamber. This creates an increased pressure gradi-
ent between the anterior and posterior chambers
causing anterior bowing of the iris, narrowing of
the angle, and acute or chronic iridotrabecular
contact. Usually the anterior segment structures
appear normal; however, occasionally, there may
abnormalities of the iris architecture (thickness,
orientation, muscle tone) that may be contributing
factors. Laser iridotomy relieves the pressure
difference between the anterior and posterior
chambers. This reduces the iris convexity, the iris

Table 1. Classication of primary angle closure (PAC)

Acute primary angle closure
(APAC)
Primary angle closure
suspect (PACS)
Primary angle closure
(PAC)
Primary angle closure
glaucoma (PACG)
Symptoms: ocular/periocular pain, nausea and/or vomiting, a history of intermittent blurring of
vision with halos, IOP W21 mmHg
Signs: conjunctival injection, corneal epithelial oedema, mid-dilated unreactive pupil, shallow
anterior chamber, and/or occudable angle
Contact between peripheral iris and posterior trabecular meshwork is considered possible
Eye otherwise normal
Occludable drainage angle with trabecular meshwork obstruction by peripheral iris by PAS, raised
IOP, iris whorling, glaucomecken, iris opacities, excessive pigment deposition on trabecular
surface
No optic disc damage
PAC with evidence of GON

becomes atter and the iridocorneal angle widens.
The area of iridolenticular contact increases, as
aqueous ows through the iridotomy rather than
the pupillary space (Foster et al., 2006).
Level II ciliary body
Abnormal ciliary body position leads to anteriorly
positioned ciliary processes, these force the peri-
pheral iris into the angle causing angle closure.
This is known as plateau iris. Examining the angle
with gonioscopy will show the iris root angulated
forward and centrally. Laser iridotomy partially
opens or fails to open the angle. Therefore laser
iridoplasty is the treatment of choice. Plateau iris
syndrome occurs when angle closure develops,
either spontaneously or after pupillary dilation, in
an eye with plateau iris conguration despite a
patent iridotomy. Other disorders of the ciliary
body may mimic plateau iris conguration and
include iridociliary cysts, tumors, or edema (Foster
et al., 2006).
Level III lens-induced glaucoma
A large lens (due to intumescence) may press
against the iris and ciliary body, forcing them
forward and therefore causing acute or chronic
angle-closure glaucoma (phacomorphic glau-
coma). This may also occur if there is anterior
subluxation of the lens (Foster et al., 2006).
Level IV malignant glaucoma
In this form of glaucoma, the pressure difference is
created between the vitreous and aqueous com-
partments due to aqueous misdirection into the
vitreous. This pushes the lensiris diaphragm
forward. Anterior rotation of the ciliary body
with forward rotation of the lensiris diaphragm
and relaxation of the zonular apparatus causes
anterior lens displacement causing angle closure by
pushing the iris against the trabecular meshwork.
A shallow supraciliary detachment maybe present
and it is this effusion that is thought to cause the
anterior rotation of the ciliary body (Foster et al.,
2006).
33
Other causes of angle closure
These include anterior subluxation of the lens, iris,
or ciliary body cysts, ciliary body tumors or
inammation, as well as air or gas bubbles after
intraocular surgery. PAS can be caused by iris and
angle neovascularization, iridocorneal endothelial
syndrome, or anterior uveitis. These disorders
need to be identied and treated specically
(Foster et al., 2006).
Risk factors
A list of the common/important risk factors for
angle-closure glaucoma are summarized in Table 2.
Age and gender
The prevalence of angle closure increases with age
(Seah et al., 1997; Wong et al., 2000; Lai et al.,
2001; Vijaya et al., 2007). The prevalence of
narrow angles, PAC, and PACG is higher in
females compared to males (Teikari et al., 1987;
Seah et al., 1997; Wong et al., 2000; Lai et al.,
2001; Ivanisevic et al., 2002; Vijaya et al., 2007).
Ethnicity
East Asian populations (Chinese from Singapore
and Hong Kong) have the highest incidence rates of
acute angle closure. Compared to East Asians,
South and South East Asians (Indians, Thais, and
Malays) have lower rates of angle-closure. It is noted
that only 2535% of angle closure in Asian people
causes symptoms (Foster et al., 1996, 2000; Congdon
et al., 1996; Yip and Foster, 2006). The highest rates
of angle-closure glaucoma are found in the Inuits of
Alaska, Canada, and Greenland (Alsbirk, 1976;
Table 2. Risk factors for angle closure
Increasing age
Female gender
Ethnicity: Inuits and East Asians
Shallow anterior chamber depth
Shorter axial length
Genetic factors
34
Arkell et al., 1987). Studies from India show that
PACG is more common in India than in Europeans
and has a tendency to be asymptomatic (Jacob et al.,
1998; Dandona et al., 2000). PAC is not a common
condition in Europeans; its prevalence rate is 0.1%
or less in people over 40 years old (Hollows and
Graham, 1966; Coffey et al., 1993; Wensor et al.,
1998). In the African population, a study has shown
that the rate of PAC was equal among black and
white populations in Johannesburg (Luntz, 1973);
however, studies looking at people of Bantu
ethnicity have shown a prevalence of PACG at
0.5% much lower then the prevalence of other
glaucomas (Buhrmann et al., 2000).
Ocular biometry
Anterior chamber depth (ACD) is the most
important anatomical risk factor for angle-closure
(Yip and Foster, 2006). A shallower ACD leads to
an increased risk of angle closure, and this collates
to demographic factors. ACD is shallower in
females and decreases with increasing age (Alsbirk,
1974; Foster et al., 1997). This age-related change
is also more pronounced in women than men
(Alsbirk, 1976; Foster et al., 1997).
As the position and thickness of the lens
determines the ACD, these factors are the ultimate
determinants of the risk of angle-closure. A study
comparing normals with angle closure in Austra-
lians found the ACD to be 1.0 mm shallower in the
PAC group. 66% of this difference was due to the
more anterior positioning of the lens and 33% was
due to the lens being thicker than normal (Lowe,
1969). A later study of Chinese people found lens
thickness was the major determinant of a shallow
ACD. The lens position only accounted for 4% of
the difference between angle closure and normal
eyes (Friedman et al., 2003).
Subjects with angle closure have shorter axial
lengths (Lowe, 1977). Studies in both Chinese and
Indian populations have shown that affected
people have shorter axial lengths compared to
those classied as normal. Also, eyes suffering from
acute angle closure have shorter axial lengths population (Aung et al., 2005b). An association
than those affected by the chronic, asympto- between a single nucleotide polymorphism in
matic angle closure (Lin et al., 1997; Sihota et al.,
2000; George et al., 2003). Therefore in patients
with angle closure, the anterior segment is more
crowded as the lens is thicker and more anteriorly
located. This is conrmed by ultrasound biomicro-
scopy (UBM), which demonstrates forward rota-
tion of the ciliary processes (Marchini et al., 1998).
Studies from Mongolia and Singapore clearly
show PAS development increases with reduction in
ACD (Aung et al., 2005a). Interestingly, in the
Singaporean population there was a consistent
increase in PAS across the range of ACD but in
the Mongolian population there was a clear
threshold (2.4 mm) at or above which PAS was
very uncommon (Aung et al., 2005a).
Genetics
Relative to POAG, PACG has been poorly
researched. A genetic locus for PACG has not
been published and candidate-gene-association
studies have not been reported. Tornquist rst
suggested that PACG was transmitted by a single
dominant gene in 1953. Ocular characteristics
related to angle-closure glaucoma, namely, the
anterior positioning of the lens, increased lens
thickness, and shallow anterior chambers are more
common in close relatives of affected patients than
in the general population (Lowe, 1964, 1972;
Tomlinson and Leighton, 1973; Alsbirk, 1975).
Recently, a study into the heritability of ACD as
an intermediate phenotype of angle closure found
additive genetic effects appear to be the major
contributor to the variation of ACD and relative
ACD (ACD/axial length) in Chinese twins (He
et al., 2008). Small studies have reported that
PACG subjects may carry a mutation in the
myocilin gene (MYOC) (Faucher et al., 2002;
Vincent et al., 2002). It is thought that in POAG,
mutant MYOC proteins accumulate in the trabe-
cular meshwork, impairing aqueous humor outow
(Jacobson et al., 2001). However, molecular
analysis of the MYOC gene in 106 Chinese patients
with chronic PACG was negative and did not
support the role of MYOC mutation in the
pathogenesis of chronic PACG in the Chinese
matrix metallopeptidase 9 (MMP-9) gene and acute
PAC has also been reported (Wang et al., 2006).
 35

Diagnosis associated with an acute rise in IOP with ocular

Acute primary angle closure
The diagnosis of APAC is mainly clinical. There is
a sudden, usually symptomatic rise in IOP. This is
usually unilateral, but bilateral simultaneous
attacks can occur. Patients complain of periocular
or ocular pain, headache, nausea, and/or vomiting.
The patients also complain of blurring of vision
with haloes. Slit lamp examination will reveal
conjunctival injection, corneal epithelial edema
with a mid dilated sluggish/nonreacting pupil. The
IOP is likely to be greater than 30 mmHg. The
anterior chamber will be shallow and gonioscopy
will show occludable or occluded drainage angles
in both eyes. In some instances, if there is a severe
anterior chamber reaction, with hypopyon, the
IOP maybe normal or low due to ciliary body
shutdown. It is important that these episodes of
APAC are not misdiagnosed as uveitis. Also,
certain types of open angle glaucoma can be
pain, conjunctival injection, and corneal edema.
These include phacolytic glaucoma, Posner
Schlossman syndrome, pseudoexfoliative glau-
coma, and neovascular glaucoma.
Angle assessment in angle closure
In angle closure, the drainage angle is occludable
and there are features indicating that trabecular
obstruction has occurred like PAS. The gold
standard technique to diagnose angle closure is
gonioscopy. There are three widely used grading
systems. The Scheie scheme is based on the angle
structures seen during gonioscopy (Scheie, 1957).
The Shaffer system requires the assessment of the
angular distance between the iris and cornea
(Becker and Shaffer, 1965). The Spaeth scheme
allows for more detailed recording of the angle
characteristics (geometric angle, iris prole, true and
apparent level of insertion) (Spaeth, 1971). Table 3
gives a summary of the grading systems (Scheie,

Table 3. Gonioscopy grading systems

0 I II III IV

Shaffer Closed 101 201 301 401

Modied Schwalbes line not Schwalbes line Anterior trabecular Scleral spur is visible Ciliary band is visible
Shaffer visible visible meshwork is visible
Scheie Ciliary band is Last roll of iris Nothing posterior to Posterior portion of No structures posterior
visible obscures ciliary the trabecular trabecular meshwork to Schwalbes line visible
body meshwork is visible is hidden

Spaeth system

(1) Iris insertion Anterior to Schwalbes line

Behind Schwalbes line
Centred at scleral spur
Deep to scleral spur
Extremely deep/on ciliary band
(2) Angle width Slit
101
201
301
401
(3) Peripheral iris conguration Queerly concave
Regular
Steep
(4) Trabecular meshwork pigment 0 (none) to 4 (maximal)
36
1957; Becker and Shaffer, 1965; Spaeth, 1971; South
East Asia Glaucoma Interest Group, 2008). The
Goldmann lens gives a stable, clear view of the
important landmarks but indentation of apposition-
ally closed angles using this lens has not been
validated, and is difcult as the curvature of the lens
is more than the corneal curvature. Therefore, the
use of a four-mirror, like the Zeiss four-mirror is
necessary. This lens has the same radius of curvature
as the cornea so the patients own tear lm functions
as a coupling agent. The Goldmann-type lenses
require an optical coupling agent.
Gonioscopy technique
Gonioscopy should be carried out in a darkened
room. The patient should have adequate topical
anasthesia and should be looking in the primary
position. The slit lamp beam should be 1 mm high
and narrow. The light must be kept away from the
pupil, at the lowest illumination that will allow angle
visualization. The lens can be moved minimally along
the cornea to see over the convexity of the iris,
however, care must be taken not to apply pressure
and cause indentation. Using high magnication, the
termination of the corneal wedge (which marks the
anterior edge of the trabecular meshwork) can be
identied. Additionally, it is important to locate the
scleral spur as the trabecular meshwork is directly
anterior to this structure. Assessment of whether the
iris is in contact with the trabecular meshwork is
done. If it is not, the angle between the trabecular
meshwork and adjacent peripheral iris is estimated
and the level of the most anterior point of contact
between the iris and angle structures is described.
This is carried out for all four quadrants, then
dynamic gonioscopy can be carried out.
If Goldmann-style lenses are being used, the
patient should be instructed to look toward the
mirror, the examiner should then press on the rim
of the lens overlying the mirror, so as to indent the
central cornea. The accuracy of indentation using
this method has not been validated. The ideal
technique involves using another goniolens with a
diameter smaller than the corneal diameter, e.g. a
four-mirror Zeiss lens. Pressure should be applied
over the cornea, so as to displace aqueous from the
centre of the anterior chamber into the periphery,
pushing the iris posteriorly, falsely opening the
drainage angle. This allows one to assess whether
the iridotrabecular contact is appositional or
synechial (i.e. permanent). The extent of the
synechial closure should be assessed. Once it is
determined that the angle is indeed occludable, the
slit beam height and illumination and room lights
should be turned up ideally prior to indentation
gonioscopy to look for PAS. Any pseudo-PAS
would open up with bright light besides the pressure
applied on the cornea. Iris processes should not be
confused with PAS. Iris processes are uveal exten-
sions from the iris on to the trabecular meshwork
and occur in normal angles. Figure 1 shows the
normal angle anatomy.
Ultrasound biomicroscopy (UBM)
UBM gives good qualitative information about the
drainage angle including visualization of the ciliary
body. However, highly reproducible quantitative
information is dependent on examiner technique
and experience. UBM is usually performed with the
patient in the supine position. A suitably sized eye
cup (around 20 mm) is inserted between the eyelids
and the coupling medium (e.g. methylcellulose
and/or normal saline) is inserted into it. The probe
is then inserted into the medium and real time images
are displayed on a video monitor. These can be
stored and/or printed out for analysis. It should be
noted that room illumination and accommodation
must be kept constant. Also the conguration of the
anterior segment and the proportions of the
structures seen depends on the plane of the section
and any degree of tilt in the scanning probe
(Liebmann, 2006). Figure 2 shows an UBM scan
of narrow angles.
Kumar et al. (2008) have used the UBM to dene
plateau iris. The features of UBM are dened in
each quadrant, and include the presence of an
anteriorly directed ciliary body, an absent ciliary
sulcus, a steep iris root from its point of insertion
followed by a downward angulation from the
corneoscleral wall, presence of a central at iris
plane, and irido-angle contact. At least two quad-
rants have to fulll the above criteria for plateau iris
to be dened (Kumar et al., 2008). Figure 3 shows
the features.
 37

Fig. 1. Gonioscopic view of normal angle anatomy, showing iris (I), ciliary body band (CBB), scleral spur (SS), posterior
trabecular meshwork (PTM), anterior trabecular meshwork (ATM), and Schwalbes line (SL). Iris processes can also be clearly seen (IP).
(Courtesy of Lisandro Sakata, MD, PhD, University of Alabama, Birmingham, USA.) (See Color Plate 4.1 in color plate section.)

Fig. 2. The gure shows an ultrasound biomicroscopy scan of a closed angle; there is iridocorneal touch, obstructing the trabecular
meshwork.

Anterior segment optical coherence tomography
(AS-OCT)
The AS-OCT is a noncontact instrument that
rapidly obtains high-resolution images of the
angle and anterior chamber using infrared light
(Baskaran, 2006). Unlike the UBM it cannot image
the ciliary body. The image capture scan takes a few
seconds and is akin to taking a photograph. The
device allows qualitative and quantitative angle
38

Fig. 3. The gure shows an ultrasound biomicroscopy image of a quadrant showing plateau iris after laser peripheral iridotomy.
Features shown: (A) irido-angle touch, (B) anteriorly rotated ciliary process, (C) absent ciliary sulcus, and (D) iris angulation.
(Courtsey of Rajesh Kumar, MS, Singapore National Eye Centre, Singapore.)

imaging, which is objective and reproducible.
Research comparing UBM, AS-OCT, and gonio-
scopy shows the AS-OCT is good at identifying
narrow angles; however, the device does identify
more subjects as having closed angles than
gonioscopy (Radhakrishnan et al., 2005, 2007).
Figure 4 shows an AS-OCT scan of an eye with
narrow angles.
Scanning peripheral anterior chamber depth
analyzer (SPAC)
The SPAC does not image the angle per se but
takes rapid slit images of the central and peripheral
anterior chamber using an optical method and
creates an iris anterior surface contour using these
measurements. This is then graded and compared
to the normative database and the resultant grade
gives a risk assessment for the patient (Kashiwagi
et al., 2004). The SPAC correlates well with the
modied van Herick system in grading peripheral
ACD. However, it overestimates the proportion of
narrow angles relative to gonioscopy and the
modied van Herick grading system (Baskaran
et al., 2007).
Visual-field loss
It has been observed that the pattern of visual-eld
loss in PACG is different from that of POAG.
Gazzard et al. showed that subjects with POAG
had greater superior hemield loss than in the
inferior hemield. This difference between the two
hemields was less pronounced in the PACG
patients. However, the PACG group exhibited
more severe visual-eld loss compared to the
POAG group. The authors postulated that POAG
is thought to be due to a combination of pressure
dependent and independent mechanisms whereas
PACG is predominantly pressure related. This
may be why there is less of a difference between the
two hemields in PACG patients. The reason for
the more severe eld loss is less clear and maybe
due to the tendency of PACG patients to present
later (Gazzard et al., 2002).

Fig. 4. The gure shows an anterior segment-optical coherence tomography scan of narrow angles. (Courtsey of Lavayana Raghavan,
DO, Singapore National Eye Centre, Singapore.)
Management
Acute primary angle closure
The aims of the treatment of APAC are to achieve
rapid control of IOP, so as to limit optic-nerve
damage and eliminate pupil block. The patient
should then be monitored for subsequent IOP
elevation and development of PACG. The manage-
ment should be tailored for the fellow eye as well.
Medical therapy
This aids the rapid reduction in IOP. Intravenous
carbonic anhydrase inhibitors (e.g. acetazolamide)
usually have a rapid IOP lowering affect. 500 mg
of acetazolamide is usually given intravenously,
together with an oral dose of 500 mg (if the patient
is not vomiting). The side effects of acetazolamide
include paraesthesia, drowsiness, confusion, loss of
appetite, polydipsia, and polyuria. It can also
cause metabolic acidosis and electrolyte distur-
bance, respiratory failure, and StevensJohnson
syndrome (Lam et al., 2007). Therefore, it is
important to test blood for urea and electrolytes.
The inammation in the eye is controlled by
topical steroids (e.g. dexamethasone 0.1% or
prednisolone 1%). Topical IOP lowering medica-
tions (e.g. beta blockers and alpha2 adrenergics)
should also be given. The patients can be in pain
with nausea and vomiting, so analgesics and
antiemetics should also be given as supportive
measures. Also the patient should be laid supine to
39
prevent further forward movement of the lens
(Choong et al., 1999).
Miotics usually open the angle by pulling the
peripheral iris away from the angle. However, in
some eyes, miotics may increase the axial lens
thickness and loosen the zonules, allowing for
anterior lens movement, and thereby inducing
further angle closure (Kobayashi et al., 1999). Due
to this, it is preferable to withhold pilocarpine until
the IOP has been reduced. Usually the pressure is
rechecked 1 h after the commencement of treat-
ment and pilocarpine is given then (Choong et al.,
1999).
After 2 h, if the IOP is still above 35 mmHg, a
hyperosmotic agent (e.g. 20% mannitol 12 g/kg)
should be given intravenously for over 45 min. If
there is no vomiting oral hyperosmotic agent (e.g.
glycerol 1 g/kg) may be given as an alternative.
Due care must be given as acidosis, pulmonary
edema, congestive heart failure, dehydration, and
acute renal failure are all side effects of hyper-
osmotics. Glycerol may cause ketoacidosis in
diabetics.
Argon laser peripheral iridoplasty (ALPI)
If there are contraindications to systemic medica-
tions or the IOP is still elevated after some time,
the next stage is to perform an ALPI. It involves
the placement of a ring of contraction burns on the
peripheral iris to contract the iris stroma near the
angle, mechanically pulling open the angle. This
allows for the eye to become quiet before the
40
denitive treatment of laser peripheral iridotomy
(PI) can be carried out. It has the advantage of
being able to be performed in eyes with relatively
hazy corneas and shallow angles; also it avoids the
risks of complications from systemic therapy
especially in APAC patients who are usually
elderly with coexisting medical conditions. ALPI
also opens the angles in eyes with plateau iris
(Ritch et al., 2004).
The laser is performed with either an argon or
diode laser. Either an Abraham (+66 dioptre) or
Wise lens (+103 dioptre) is used. The burns are
placed at the iris periphery as close to the limbus
as possible. If bubbles or charring occur, the
laser energy should be reduced. Four to six burns
are placed per quadrant for a total of two to
four quadrants (spot size 200500 mm, energy
100400 mW, duration 0.20.5 s).
Complications of iridoplasty include corneal
endothelial cell damage, iris atrophy, inamma-
tion, and PAS.
In cases where laser iridoplasty is not available,
immediate anterior chamber paracentesis has been
proposed as an alternative procedure to rapidly
lower the IOP in APAC (Lam et al., 2007).
Laser peripheral iridotomy (PI)
Once the IOP is controlled and the cornea has
cleared sufciently, a laser PI can be carried out.
This eliminates the pupil block. In Asian eyes,
(which usually have thick brown irides) sequential
use of the argon and neodyuim: yttrium-aluminum-
garnet (Nd:YAG) lasers are used to create a PI,
allowing for less total laser energy (Lim et al.,
1996). In Caucasian eyes, with thinner irides,
Nd:YAG laser may only be used. Burns with a
small spot size, short duration, and high energy are
placed as far in the iris periphery as possible
between 11and 2 oclock positions. Care should be
taken to avoid corneal burns.
First the iridotomy lens (Wise or Abrahams) is
placed on the eye and argon laser is used to place
four to six spots of about 600 mW in an over-
lapping pattern. The centre is then deepened with
the energy increasing to achieve patency (spot size
50 mm, energy 6001400 mW, duration 0.010.1 s).
The PI is then enlarged with the Nd:YAG laser
(power 1.46 mJ).
Complications of PI include corneal endothelial
damage, hemorrhage, cataract formation, imper-
forate PI, glare, retinal burns, IOP spikes, and
malignant glaucoma. The post laser spikes can be
reduced with perioperative use of alpha-2 agonists
like brimonidine or apraclonidine (Chen et al.,
2001).
Lens extraction
Removal of the crystalline lens deepens the
anterior chamber and widens the drainage angle.
In one report, it had a success rate of about 70%
even if the eyes have signicant PAS. Also, there
were fewer additional surgical interventions and
sight-threatening complications compared to tra-
beculectomy (Ming Zhi et al., 2003).
The preliminary results of a randomized con-
trol trial comparing phacoemulsication and con-
ventional argon laser PI after APAC has shown an
IOP rise of 3.2% in the phacoemulsication group
compared to 28.3% in the iridotomy group.
Surgery was performed 773 days after aborting
the APAC. The authors felt that phacoemulsica-
tion can be carried out soon after aborting APAC
but was not without risk and felt a better option
was to perform surgery about 4 weeks after APAC
when the eye had settled down adequately and the
IOP had not yet risen (Lam et al., 2007).
It is notable that lens removal does not remove
the risk of angle closure in eyes with plateau iris
syndrome (Tran et al., 2003).
Monitoring for subsequent IOP rise in eyes with
APAC
In Caucasians, 70% of APAC is controlled by PI
alone. However, in Asians, as many as 58% of eyes
develop an increased IOP after resolution of the
acute event. 77% of these eyes developed the
increase within 6 months of the acute episode and
33% required glaucoma ltering surgery (Aung
et al., 2001). These eyes require long-term follow
up, especially those with optic-nerve damage,
W50% PAS, failure of initial medical therapy to

lower initial IOP, and delayed presentation (Nolan
et al., 2000).
Fellow eye of APAC
The fellow eye will have the same dimensions as
the attack eye and therefore is at high risk of
APAC as well. Therefore a prophylactic PI should
be carried out for the fellow eye. This will prevent
APAC, however 10% may still have a rise in IOP
over time and therefore require close monitoring
including regular gonioscopy. Figure 5 is a ow
diagram for the management of APAC.
Chronic primary angle-closure glaucoma (CACG)
The aim of treatment is to eliminate the underlying
pathophysioloical mechanism causing the angle
closure (mainly pupil block and peripheral angle
crowding/plateau iris).
Laser peripheral iridotomy
All CACG patients should undergo PIs. However,
this is an unsatisfactory long-term therapy in the
sense that additional treatment is often required,
particularly for eyes with GON. The majority of
patients require further medication or surgery to
control IOP (Alsagoff et al., 2000).
Laser iridoplasty
If the patient has plateau iris or peripheral
crowding of the angle, i.e. the angle remains
occludable after PI, then peripheral iridoplasty
can be considered. It should be carried out early in
the disease course as laser iridoplasty might not be
effective when PACG is well established or when
medical therapy has already failed, or in the
presence of extensive PAS.
Medical therapy
The need for further medical therapy after
iridotomy is determined by IOP and the extent of
glaucomatous damage. This is common in Asian
41
patients and can be difcult to manage (Ritch and
Lowe, 1996b). It is known as residual CACG
after iridectomy or iridotomy. Usually, nonpupil
block mechanisms including lens factors, plateau
iris, and damage to the trabecular meshwork, are
the cause (Ritch and Lowe, 1996b).
Medical therapy entails the use beta-adrenergic
agonists, alpha2 adrenergic agonists, mitotics,
topical carbonic anhydrase inhibitors, and pros-
taglandins. Of note long-term miotic treatment in
the absence of an iridotomy may expedite the
development of acute angle closure. Low dose
pilocarpine can be used as an alternative to
iridoplasty in plateau iris syndrome. Studies
have shown that the prostaglandin, latanoprost,
is more effective than the beta-blocker, timolol,
in lowering IOP in PACG patients. It is thought
that latanoprost enhances aqueous humor access
to the ciliary body via the still open part of the
drainage angle (Aung et al., 2000; Chew et al.,
2004).
Trabeculectomy
This is indicated when the IOP cannot be
controlled by laser iridotomy or medication, if
there is evidence of continuing glaucomatous
damage, poor compliance or intolerance to medi-
cal treatment, or poorly controlled glaucoma at
the time of planned cataract surgery. The use of
antiscarring agents is also similar to that of
POAG, i.e. eyes at high risk of failure of surgery
(e.g. those with previous failed trabeculectomy),
eyes with advanced disease (extensive PAS, optic-
nerve damage, and visual-eld loss), and eyes on
multiple medications (Aung, 2006).
Lens extraction
It is postulated that removal of the lens leads to
deepening of the anterior chamber, resulting in
reduction of angle crowding and the relief of pupil
block. A prospective case series carried out in
Hong Kong found both the IOP and requirement
for glaucoma drugs reduced signicantly after
cataract extraction (Lai et al., 2006).
42

Acute Angle Closure

Intravenous acetazolamide Medical therapy contraindicated

500mg +/- oral 500mg
Tropical Steriods
Tropical blockers, 2-
agonists
Lay patients flat
Antiemetics
Analgesia

Recheck IOP in1 hour

If IOP reduced, give
pilocarpine to affected
eye
2 hours later
IOP>35mmHg

Intravenous mannitol, 1-2 g/kg over 45mins

or oral glycerol, 1g/kg if not vomiting

2 hours later
IOP > 35mHg

If laser peripheral
iridoplasty not available
Laser peripheral iridoplasty
? Anterior chamber
paracentesis

IOP controlled and cornea clears

Laser peripheral iridotomy

(NB fellow eye will require laser peripheral iridotomy as well)
? Lens extraction

Monitor patient for subsequent IOP rise

Fig. 5. Management of acute angle closure.

 43

Combined lens extraction and trabeculectomy GON glaucomatous optic neuropathy

surgery IOP intraocular pressure
kg kilograms
Combined lens extraction and ltration surgery mg milligrams
also has a role in the management of CACG. This mmHg millimeters of mercury
allows for visual rehabilitation after cataract MMP-9 matrix metallopeptidase 9
extraction, prevention of IOP spikes in the mW illiwatts
immediate post-operative period, and widening MYOC myocilin gene
of the angle after lens removal with improved IOP Nd:YAG neodyuim:yttrium-aluminum-
control. A retrospective study from Singapore garnet
showed that combined phacoemuliscation with PAC primary angle closure
posterior chamber intraocular lens implantation PACG primary closed angle glaucoma
and trabeculectomy was associated with good IOP PACS primary angle-closure suspect
control and visual outcome in patients with PACG PAS peripheral anterior synechiae
(Aung, 2006). Another study found the complica- PI laser peripheral iridotomy
tion rates of phacotrabeculectomy were similar in POAG primary open angle glaucoma
PACG and POAG (Aung, 2006). s seconds
SPAC scanning peripheral anterior
chamber depth analyzer
Goniosynechialysis UBM ultrasound biomicroscopy
% percent
This procedure involves the stripping of PAS from mm micrometers
the angle wall, therefore opening the angle and
restoring trabecular function. It is another surgical
option for the treatment of CACG and is more
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