Introduction to Glaucoma: Part 2 - Anterior Segment & Ocular Disease Fall 2025

primary angle closure glaucoma

appositional or synechial closure of the anterior chamber angle

aqueous outflow will be reduced which will lead to an increase in IOP

What happens to aqueous flow during primary angle closure glaucoma?

50+ yo

What is the onset of primary angle closure glaucoma?

Asia -- higher incidence of myopes with flatter cornea and narrow anterior chamber

Where is primary angle closure glaucoma common?

females

Who is more affected by primary angle closure glaucoma?

Females or males

yes

Are there multiple mechanisms possible for the development of primary angle closure glaucoma?

pupillary block

What is a key element in most variants of primary angle closure glaucoma?

aqueous is blocked from traveling from the posterior chamber to the anterior chamber

What happens during pupillary block with primary angle closure glaucoma?

d/t posterior synechia

What is pupillary block usually d/t with primary angle closure glaucoma?

the iris will bow forward d/t the increase volume of aqueous in the posterior chamber

What happens to the iris with pupillary block?

iris adheres to and blocks the TM, aqueous cannot flow through

What happens d/t iris bowing forward with pupillary block?

-hyperopia

-shorter axial length

-shallow anterior chamber

-family hx

-thicker crystalline lens

What are the risk factors for primary angle closure glaucoma?

-primary angle closure suspect

-primary angle closure

-primary angle closure glaucoma

**step wise progression, patients can present at any point

What are the possible types of primary angle closure glaucoma?

an individual with anatomically narrow angle width

What is the definition of primary angle closure suspect?

no symptoms

What are the symptoms of a primary angle closure suspect?

-narrow anterior chamber with LESS THAN 180º of iridotrabecular contact (ITC)

What is the presentation of a primary angle closure suspect?

no peripheral anterior synechiae

With a primary angle closure suspect, will there be ANY adhesions of the iris and the TM?

no -- they are all normal

With a primary angle closure suspect, are the IOP, optic nerve or VFs affected?

-subacute angle closure attacks

-progression into primary angle closure

What are the possible complications that can occur in a primary angle closure suspect?

individual will sporadically go into and out of partial angle closure attacks

What happens when a patient experiences subacute angle closure attacks?

-will present with intermittent symptoms of blurred vision or halos due to mild corneal edema

-intermittent HAs in brow area

-intermittent elevations in IOP

How will a patient present during a subacute angle closure attack?

when in a dark room, with night driving, or with dilation

When do the symptoms of subacute angle closure attacks seem to be worse?

peripheral iridotomy (PI)

What is the treatment that we should present to a patient that is a primary angle closure suspect?

primary angle closure

individual with anatomical narrow angles with BLOCKAGE of the TM

none, unless experiencing acute angle closure crisis

What are the symptoms of primary angle closure?

-three qradrants of iridotrabecular contact (ITC)

-elevated IOP d/t less aqueous outflow

-peripheral anterior synechiae may be present

-normal retinal nerve fiber layer, optic nerve, and VF

What is the presentation of primary angle closure?

No -- cannot break these

Are peripheral anterior synechiae reversible?

peripheral iridotomy

What is the treatment for primary angle closure?

acute angle closure crisis

individual with anatomical narrow angles with blockage of the TM and an ACUTE INCREASE in IOP

primary angle closure glaucoma

What is acute angle closure crisis considered to be a complication of?

yes -- an ocular emergency

Is acute angle closure crisis an emergency?

-significantly reduced VA

-glare or halos with lights d/t corneal edema

-gastointestinal symptoms (abdominal pain, nausea, vomiting)

What are the symptoms of acute angle closure crisis?

-narrow anterior chamber with iridotrabecular touch

-corneal edema

-circumlimbal conj hyperemia

-elevated IOP (50-80mmHg)

-anterior uveitis

-non-reactive, mid dilated vertically oval pupil

-fellow eye shows an occludable angle

What is the presentation of acute angle closure crisis?

d/t sphincter ischemia

Why are the pupils nonreactive and mid dilated during acute angle closure crisis?

-development of primary angle closure glaucoma

-pupil distortion d/t iris sphincter damage

-glaukomflecken cataract

-peripheal anterior synechiae

-low IOP d/t ciliary body ischemia

What are the complications of acute angle closure crisis?

-acetazolamide

-topical beta blocker and topicla alpha-2 agonist

-topical corticosteroid

-topical pilocarpine

-oral pain meds/antiemetic meds

-Once IOP is controlled and corneal edema improved, peripheral iridotomy

What is the treatment for acute angle closure crisis?

given via IV

If IOP is greater than 50mmHg, how is acetazolamide given to patients in acute angle closure crisis?

orally

If IOP is less than 50mmHg, how is acetazolamide given to patients in acute angle closure crisis?

use caution with IOP is above 40mmHg as iris sphincter ischemia may occur

When is oral pilocarpine given to patients in acute angle closure crisis?

decrease aqueous production

What is the function of the beta blocker and alpha-2 agonist given to patients in acute angle closure crisis?

primary angle closure glaucoma

individual with anatomically narrow angles with BLOCKAGE of the TM and additional GLUACOMATOUS FiNDingS

decreased vision and reduction in peripheral vision

What are the symptoms of primary angle closure glaucoma?

-three quadrants of iridotrabecular contact

-elevated IOP

-retinal nerve fiber thinning

-glaucomatous optic nerve appearance

-glaucomatous visual field defects

What is the presentation of primary angle closure glaucoma?

topical glaucoma mediations and peripheral iridotomy

What is the treatment for primary angle closure glaucoma?

decreased vision and reduction in peripheral vision

What are the symptoms of primary angle closure glaucoma?

-three quadrants of iridotrabecular contact

-elevated IOP

-retinal nerve fiber thinning

-glaucomatous optic nerve appearance

-glaucomatous VF defects

What is the presentation of a patient with primary angle closure glaucoma?

topical glaucoma medications and peripheral iridotomy

What is the treatment for a patient with primary angle closure glaucoma?

chronic angle closure glaucoma

What is a possible complication of primary angle closure glaucoma?

none -- patient may develop blurred vision if IOP is high

What are the symptoms of chronic angle closure glaucoma?

-elevated IOP

-intermittent areas of iridotrabecular contact with peripheral anterior synechiae

-eventually entire angle will close 360º

-retinal nerve fiber thinning

-glaucomatous optic nerve

What is the presentation of chronic angle closure glaucoma?

-surgical

-peripheral iridotomy

-iridoplasty

-trabeculectomy

What is the treatment for chronic angle closure glaucoma?

plateau iris configuration

form of angle closure by an anteriorly displaced ciliary body

30-50yo

What is the onset of plateau iris configuration?

females

Is plateau iris configuration more common in males or females?

-hyperopic

-fam hx of angle closure

What are the risk factors for plateau iris configuration?

-ciliary body will be anteriorly displaced due to a short iris root

-peripheral iris will move forward

-when the pupil dilates, the iris will bunch together and block the TM

-IOP will rise

What is the pathophysiology of plateau iris configuration?

-blurry vision with halos

-eye pain

-HA

-vomiting/nausea

What are the symptoms of plateau iris configuration?

-normal anterior chamber depth

-flat iris surface

-narrow angle seen with gonioscopy

What is the presentation of plateau iris configuration?

plateau iris syndrome

What is the possible complication of plateau iris configuration?

angle closure in the presence of a patent peripheral iridotomy

What is the definition of plateau iris syndrome?

-peripheral iridotomy

-iridoplasty

What is the treatment for plateau iris configuration?

secondary glaucoma

development of glaucoma as a consequence of another eye condition or systemic condition

-open angle

-closed angle

What are the 2 classifications of secondary glaucoma?

-pretrabecular

-trabecular

What are the subtype of open angle glaucoma?

blockage of the TM d/t a membrane

What is pretrabecular open angle secondary glaucoma?

blockage of the TM d/t obstruction or blockage

What is trabecular open angle secondary glaucoma?

-with pupillary block

-without pupillary block

What are the subdivisions of closed angle secondary glaucoma?

pseudoexfoliation

systemic condition in which there is an abnormal production or turnover of extracellular matrix in the basement membrane

50 yo with rapid increase in prevalence after 60yo

What is the onset of pseudoexfoliation?

females

Is pseudoexfoliation more common in males or females?

Scandinavia

Where is pseudoexfoliation most common?

hearing loss, cardiovascular disorders

What have been associated with pseudoexfoliation?

-grey-white fibrillary material is deposited on the lens capsule, zonular fibers, iris and TM

-fibrillary material is produced by iris, lens epithelium, ciliary body or TM

What is the pathogenesis of pseudoexfoliation?

-pseudoexfoliation syndrome

-pseudoexfoliation glaucoma

What are the 2 ocular manifestations of pseudoexfoliation?

no symptoms

What are the symptoms of pseudoexfoliation syndrome?

-dandriff like material deposited on lens, anterior chamber and iris

What is the presentation of pseudoexfoliation syndrome?

double concentric ring pattern -- separated by a clear zone

The dandruff like material deposited on the lens in pseudoexfoliation syndrome will look like what?

-seen near TM

-patchy areas of TM hyperpigmentation will also be seen

The dandruff like material deposited in the anterior chamber in pseudoexfoliation syndrome will look like what?

-seen at the pupillary ruff

-transillumination defects will be seen near pupillary ruff

The dandruff like material deposited on the iris in pseudoexfoliation syndrome will look like what?

pseudoexfoliation glaucoma

What are the complications of pseudoexfoliation syndrome?

true

True or False:

The risk of developing glaucoma increases the longer the patient has pseudoexfoliation syndrome

60

____% of patients with pseudoexfoliation syndrome are diagnosed with glaucoma at 5 years

increased IOP, retinal nerve fiber thinning, glaucomatous optic nerves, VF defects

Patients with pseudoexfoliation glaucoma will have what?

decreased VA and reduced peripheral vision

increased IOP, retinal nerve fiber thinning, glaucomatous optic nerves, VF defects d/t pseudoexfoliation syndrome can lead to what?

pseudoexfoliation glaucoma

Which has a more rapid progression?

pseudoexfoliation glaucoma or primary open angle glaucoma

no treatment is needed for pseudoexfoliation syndrome

What is the treatment for pseudoexfoliation syndrome?

-topical glaucoma meds

-surgical management with trabeculoplasty, trabeculectomy, tube shunt, or ciliary body destruction

What is the treatment for pseudoexfoliation glaucoma?

pigment dispersion syndrome

release of pigment granules from the iris pigment epithelium

throughout the anterior segment

Where will the pigment granules deposit in pigment dispersion syndrome?

white, young, myopic males

Who is pigment dispersion syndrome common in?

-excessive posterior bowing of the mid-peripheral portion of the iris

-bowing of the iris will cause posterior iris to rub against the zonules which will in the release of pigment granules

What is the pathogenesis of pigment dispersion syndrome?

decrease -- lens will thicken with accommodation

Does pigment dispersion in pigment dispersion syndrome increase or decrease with age?

-asymptomatic

-blurred vision with hals and acute increases in IOP

What are the common symptoms of pigment dispersion syndrome?

pigment deposition on the endothelium in a vertical spindle shape (Krukenberg spindle)

What is the presentation of pigment dispersion syndrome on the cornea?

-open angles with heavily pigmented trabecular meshwork

-pigment can be anterior to Schwalbe's line (Sampaolesi line)

What is the presentation of pigment dispersion syndrome in the anterior chamber (seen with gonioscopy)?

radial mid peripheral transillumination defects with pigment deposition on the anterior surface of the iris

What is the presentation of pigment dispersion syndrome on the iris?

pigment position can be seen on the anterior capsule and pigment can also be seen near the zonule insertion

What is the presentation of pigment dispersion syndrome on the lens?

increases in IOP can be seen

What is the effect of pigment dispersion syndrome on the acute intraocular pressure?

no effects

What is the effect of pigment dispersion syndrome on the optical nerve and VF?

pigment dispersion glaucoma

What is a possible complication of pigment dispersion glaucoma?