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Symptoms ⬇

Usually asymptomatic, although patients with advanced disease may present with decreased vision or visual field loss. Intermittent eye pain, headaches, and blurry vision may occur.

Signs ⬆ ⬇

(See Figure 9.5.1.)

Critical

Gonioscopy reveals broad bands of PAS in the angle. The PAS block visualization of the underlying angle structures. Glaucomatous optic nerve and visual field defects.

Other

Elevated IOP.

9-5.1 Chronic angle closure glaucoma with peripheral anterior synechiae.

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Etiology ⬆ ⬇

Gradual narrowing of the angle with prolonged appositional closure.

Prolonged acute angle closure glaucoma or multiple episodes of subclinical attacks of acute angle closure.

Previous flat anterior chamber from surgery, trauma, or hypotony that resulted in the development of PAS.

NOTE:

While acute angle closure is less common in those of African descent, chronic angle closure is more commonly seen in these patients.

Work Up ⬆ ⬇

Workup
  1. History: Presence of symptoms of previous episodes of acute angle closure? History of proliferative diabetic retinopathy, retinal vascular occlusion, or ocular ischemic syndrome? History of prior trauma, hypotony, uveitis, or intraocular surgery?
  2. Complete baseline glaucoma evaluation. See 9.1, PRIMARY OPEN-ANGLE GLAUCOMA.

Treatment ⬆ ⬇

See 9.1, PRIMARY OPEN-ANGLE GLAUCOMA.

  1. LT contraindicated in CACG and can induce greater scarring of the angle.
  2. Laser peripheral iridotomy is indicated to relieve any component of pupillary block and to prevent ongoing development of PAS if closure is not already 360 degrees. Beware of postlaser IOP spikes in these patients whose TM function may be limited.
  3. Laser iridoplasty may be performed (and repeated) to decrease the formation of new PAS. This may not be entirely effective and may serve only as a temporizing measure. If iridoplasty fails and other medical therapy has been maximized, the patient may need additional surgery. ECP may be attempted in cases with early glaucoma, but trabeculectomy or tube shunt is usually indicated in more advanced cases. MIGS usually contraindicated due to closed angle.

Follow Up ⬆

See 9.1, PRIMARY OPEN-ANGLE GLAUCOMA.