What Is Acute Angle-Closure Glaucoma?

Acute angle-closure glaucoma is an eye disease caused by a sudden increase in intraocular pressure (IOP) due to the sudden closure of the anterior chamber angle. The pathogenesis is not yet clear. Often accompanied by obvious eye pain, decreased vision, ipsilateral migraine, nausea, vomiting and other symptoms, if not treated properly in a timely manner, blindness can occur in the short term.

Basic Information

nickname: Primary acute angle-closure glaucoma
English name: acute angle-closure glaucoma
Visiting department: Ophthalmology

Multiple groups: Women over 40
Common symptoms: Severe eye pain, sudden vision loss, rainbow vision, ipsilateral headache, nausea, vomiting, fever

Causes of acute angle-closure glaucoma

The pathogenesis is not very clear.

Clinical manifestations of acute angle-closure glaucoma

The clinical manifestations are divided into 6 stages according to the disease development process:

Preclinical

No symptoms, but need treatment. It includes the following two situations:

(1) There was an acute attack in one eye, although there was no history of an attack in the other eye, but it had the characteristics of shallow anterior chamber and narrow atrial angle, and sooner or later there was a possibility of an attack.

(2) A family history of acute primary angle-closure glaucoma, shallow anterior chamber, narrow chamber angle, no history of seizures, but positive challenge test.

Prodromal period

(1) Symptoms of mild eye pain, vision loss, and rainbow vision, accompanied by ipsilateral migraine, soreness and nausea at the root of the nose and orbit.

(2) The signs are mild ciliary congestion, corneal transparency is slightly reduced, the anterior chamber is lightened slightly, the pupils are slightly enlarged, and IOP is slightly increased.

The above symptoms mostly occur after mood swings or fatigue, and often occur in the evening or night with dilated pupils. After reaching the bright place or sleeping, the pupils shrink, and the symptoms can resolve on their own. The duration is usually short, and the interval is longer, usually after 1 to 2 hours, the symptoms can completely disappear. After multiple attacks, the duration gradually extended, and the interval shortened, and the symptoms gradually worsened to the acute phase. There are also a few cases of acute exacerbations that do not go through the prodromal period.

3. Acute attack

Sudden onset, most or all of the anterior chamber angle was closed, and IOP suddenly increased.

(1) Symptoms of severe eye pain, extreme vision loss, ipsilateral migraine, orbital pain, nausea, vomiting, and even increased body temperature and accelerated pulse.

(2) Signs Conjunctival ciliary or mixed congestion, and conjunctival edema. Corneal epithelial edema, haze and opacity, loss of consciousness, brown deposits on the back wall of the cornea. The anterior chamber is extremely shallow and flashes of aqueous humor may appear, but it is lighter. Due to the increased permeability of the iris blood vessels, proteins in the plasma leak into the aqueous humor. At first, there are no planktonic cells in the aqueous humor, and brown floaters may follow. Iris edema and crypt disappear. If high intraocular pressure lasts for a long time, it can close 1 or 2 radial iris blood vessels, causing ischemic infarction of the iris in the corresponding area, and iris fan atrophy, pigment particles released from the pigment epithelium. Can settle on the posterior cornea wall, iris surface and ciliary body surface. Pupils are half-opened and vertically oval. This is due to paralysis of the pupil sphincter due to high intraocular pressure, which may have post-pupil adhesions, but is generally not severe. The milky white speckled border with sharp turbidity may appear under the anterior capsule of the lens, which is called glaucoma, and it is often located at the lens suture, and does not occur in the area covered by the iris. Glaucoma spots are permanent turbidity and are later covered by new lens fibers. Therefore, the time elapsed after an acute attack can be estimated from the depth of the glaucoma spots in the lens. Sometimes, small and small glaucoma spots can resolve. IOP increased significantly, more than 50mmHg, even up to 80mmHg or higher. The angle of the atrial angle is closed: under the anterior chamber angle, the peripheral part of the iris is attached to the trabecular meshwork. If the duration of the acute attack is short and the intraocular pressure is reduced, the angle of the angle may still be open or there is limited adhesion. If the duration is long, permanent corner adhesions are formed. Fundus: Due to corneal epithelial edema, it is often necessary to drip glycerol to temporarily clear the cornea before the fundus can be seen clearly. Visual nipples are congested, there are arterial pulses, retinal veins are dilated, and occasional retinal hemorrhage.

4. Interval

After glaucoma acute exacerbation, the anterior chamber is reopened and the IOP returns to normal after drug treatment or natural remission. The condition is temporarily relieved, which is called the intermittent period or remission period. Due to the absence of pathogenic factors such as pupil block, it will continue in the future. relapse.

(1) No discomfort in symptoms .

(2) If there is no permanent damage left after the onset of signs , except for the shallow anterior chamber and narrow chamber angle, there are no positive findings. The diagnosis can only be determined based on medical history and challenge tests.

5. chronic phase

Symptoms in the acute phase are not all relieved, and the delay is changed to chronic. Peripheral iris and trabecular meshwork are permanently adhered because the angle of the room is closed for too long.

(1) Symptoms such as mild eye pain, eye swelling, and blurred vision still appear early in the chronic phase of symptoms. Later, the symptoms disappear or there is only mild eye swelling.

(2) Signs There are still signs of acute attack at the early stage of this period, but to a lesser extent, congestion and other signs have subsided, leaving only iris atrophy, pupil dilation, and glaucoma spots. If the above signs are not present during an acute attack, the iris and pupil are normal. Adhesion occurs in the corner of the room. If the adhesion range reaches 1/2 2/3 of the angle of the corner of the room, the drainage of aqueous humor is blocked, and IOP increases. Early visual nipples are still normal. When the disease progresses to a certain stage, the optic nipples gradually develop glaucomatous pathological depression and atrophy. Visual field: Normal in the early stage, glaucomatous visual field defect appeared in the later stage, the visual field defect gradually progressed, and finally went completely blind and entered the absolute period.

6. Absolute period

Total vision loss.

(1) Symptoms Because the patient has tolerated high intraocular pressure for a long time, the symptoms are not obvious, only mild eye pain, but some cases still have obvious symptoms.

(2) Signs Conjunctival conjunctival mild ciliary congestion, dilated anterior ciliary vessels, mild corneal epithelial edema, repeated bullae or epithelial exfoliation, extremely shallow anterior chamber, cloudy lens, and high IOP. In the later stage, due to the degeneration of the entire eyeball, the IOP may be lower than normal, and the eyeball eventually shrinks. Due to the low resistance of this eyeball, corneal ulcers often occur and even develop into endophthalmitis. [1-3]

Acute angle closure glaucoma

Excitation tests can be used to assist diagnosis, such as dark room test or dark room plus prone test, that is, the patient sits or lies prone in a dark room for 1 to 2 hours, then measures IOP and checks the room angle in dark light, IOP rises 8mmHg, room angle is closed Is positive. Make the pupils dilated in a dark room, and keep awake to avoid pupil shrinkage caused by sleep. Prone positioning moves the lens forward, which can aggravate pupillary block.

Diagnosis of acute angle-closure glaucoma

According to the typical symptoms of eye swelling, eye pain, iridescence, vision loss, ipsilateral migraine, and orbital and nasal root pain, accompanied by changes in the anterior segment of the eye, such as conjunctival hyperemia, corneal epithelial edema, shallow anterior chamber and pupil dilation Signs such as elevated IOP and closed corners can be diagnosed.

The prodromal period is small and has a short duration, which is not easy to be seen by doctors. Diagnosis can be made based on a typical medical history and a characteristic shallow anterior chamber and narrow atrial angle. The symptoms and signs of acute attacks are typical, and it is not difficult to make a diagnosis.

Differential diagnosis of acute angle-closure glaucoma

Acute iridocyclitis

In an acute attack, if the symptoms are not typical or the examination is not detailed enough, sometimes it can be confused with acute iris ciliaryitis, and the two treatments are completely opposite. If the diagnosis is incorrect, the treatment may cause serious consequences, so attention should be paid to identification. . Identification points: mainly anterior chamber depth, pupil size, and IOP. In this case, the anterior chamber is shallow, the pupil is half-open, and the IOP is increased. However, the depth of the anterior chamber in acute iris ciliaryitis is normal, the pupil is reduced, there is posterior adhesion, and the IOP is normal, low, or slightly higher. In addition, there is more grayish white deposits on the posterior corneal wall of acute iris ciliary inflammation, and the aqueous humor is obviously positive, with floating matter. In acute angle-closure glaucoma, there may be a small amount of brown deposits on the posterior wall of the cornea. Positive, but generally milder.

2. Other systemic diseases

Because acute angle-closure glaucoma often has symptoms such as headache, nausea, and vomiting, it can be misdiagnosed as cerebrovascular disease or gastrointestinal system disease. Ignoring the eye examination and delaying the treatment of glaucoma, causing serious consequences and even blindness. You should inquire about the medical history in detail, and think that it may be glaucoma. As long as the necessary eye examination is done, it is not difficult to make a correct diagnosis.

Treatment of acute angle-closure glaucoma

Treatment principle

(1) Surgical treatment is the main method, and early operation should be performed after a clear diagnosis.

(2) During the acute episode, first treat with medication to open the angle of the chamber and decrease IOP. Operate after the inflammatory response subsides.

2. Routine treatment

(1) Peripheral iris resection can be performed radically in the prodromal and early intermission periods . This operation can break the pupil block, the aqueous humor can flow from the posterior chamber to the anterior chamber through the resection area, the pressure of the anterior and posterior chambers is balanced, the iris does not swell, and the angle of the chamber widens without closing. Peripheral iris resection can be performed with argon laser, YAG laser or surgery.

(2) Active rescue during acute attacks , and open the corners as soon as possible to avoid permanent corner adhesions. At high IOP, there are many surgical complications and poor results. Drugs should be used to control IOP, and surgery should be performed after the congestion and inflammation have subsided.

To reduce IOP rapidly, multiple drugs can be used at the same time: 2% pomaceae rue alkaloid; acetazolamide; glycerol; 2% lidocaine; 20% mannitol.

After the above treatments, IOP can be reduced to normal, but a miotic agent is still needed, and a carbonic anhydrase inhibitor or hypertonic agent is used as appropriate according to the IOP situation. Check the angle of the room. If the angle of the room is mostly or completely open, you can observe it for several days, and then perform the operation after the inflammation subsides. If the corner is still closed, surgery should be performed promptly.

3. Surgical treatment

In the case of pilocarpine, if the IOP is normal, the angle of the room is open or the adhesion is 3 circles, then peripheral iridectomy is performed. If IOP> 21mmHg, the corner adhesion has reached 2/3 of the circumference, and filtering surgery is needed.

(1) In the chronic phase, filtering surgery or peripheral iris resection is selected according to the IOP and the angle of the room.

(2) In the preclinical stage, it is reported that 53% to 68% will have an acute attack, so most people advocate iris resection in order to obtain cure. You can also observe closely or use a miotic agent.

(3) Continue to use miotics in absolute terms . If the pain is severe, inject alcohol after the ball and remove the eyeballs if necessary. Anti-glaucoma surgery is usually not performed for incision of the eyeball. [4-5]

References

1. Yin Jinfu, Wu Lingling, etc. Triple therapy for primary angle-closure glaucoma with cataract: Chinese Journal of Otolaryngology, 1997; 2 (6): 147.

2. Wu Lingling, Liu Jing. Laser Irisotomy for Primary Angle Closure Glaucoma: Ophthalmology, 2008, 17 (03): 157-159.

3. Wu Lingling. The role of anterior gonioscopy in the diagnosis and treatment of glaucoma: Ophthalmology, 2010, 19 (1): 11-13.

4. Wu Lingling. Timing of Glaucoma Surgery: Ophthalmology, 2007, 16 (1): 14.

5. Yao Baoqun, Wu Lingling, etc. Acute primary angle closure. Contrast angle closure after laser peripheral iris resection in the contralateral eye: Chinese Journal of Optometry and Optics, 2012, 14 (4): 234-242.