Primary angle closure glaucoma

Primary angle closure glaucoma
Definition: a condition in which there is obstruction to aqueous outflow due to partial or complete closure of the angle by peripheral iris .
Unlike POAG , the diagnosis is by examination of anterior segment and gonioscopy. Presence of a normal optic disc and absence of visual field loss does not exclude diagnosis of PACG (as it is acute so the optic nerve will not be affected and there is no change in visual field , so diagnosis is from symptoms ). In addition , there are shallow anterior chamber .
Risk factors:
1- age : average age 60 years
2- gender : female/ male = 4/1
3- race: whites 6% of glaucoma s, more common in south east Asians , Chinese and Eskimos, uncommon in blacks.
4- Family history: ocular anatomical features are inherited , Ist degree relatives are at increased risk.
Anatomical predisposing factors:
1- shallow anterior chamber
2- narrow entrance to anterior chamber angle.
3- Relative anterior location of iris lens diaphragm.
PACG can be classified in to :
1-latent PACG
2- intermittent PACG
3- acute congestive PACG.
4-Post congestive PACG
5- chronic PACG.
So we discuss the most important one which is
Acute congestive angle- closure glaucoma
This condition is caused by a sudden total closure of the angle
Clinical features:
a/ rapidly progressive impairment of visual acuity, due to corneal edema
b/ ocular pain + congestion
c/ corneal edema with epithelial vesicles
d/ shallow anterior chamber+ peripheral irido corneal touch
e/ aqueous humour flare (protein) +cells
f/ pupil: vertically oval + fixed in mid dilated position, unreactive to light and accommodation
treatment: is surgical, but initially we start medical treatment to control elevated IOP

Medical treatment:
1- IV acetazolamide : 500 mg followed by 250 mg qid orally
2- Hyper osmotic agent: -IV Mannitol 1gm/ kg of 20%
- oral glycerol 1gm/ kg with orange juice
3- topical therapy:
a/ pilocarpine 4% (4 times/day) to affected eye, it cause miosis and pull the iris
b/ pilocarpine 1%( 4 times/ day ) to unaffected eye (as prophylaxis)
c/ beta- blockers (twice / day ) only for the affected eye
d/ topical steroids: if there is convexity of the iris –lens diaphragm