canadian ophthalmological society

1. Canadian Ophthalmological Society Evidence-based Clinical Practice Guidelines for the Management of Glaucoma in the Adult Eye

3. Angle-closure glaucomas The most useful classification for angle-closure glaucoma is based upon etiology. The most important criterion is the presence or absence of pupil block, with further sub-classification into primary and secondary mechanisms. The prevalence of PACG varies significantly among different ethnic groups. Acronyms PACG = primary angle-closure glaucomaAcronyms PACG = primary angle-closure glaucoma

4. Angle-closure glaucomas Patients with PACG commonly present with1 of 3 possible scenarios: acute angle closure, narrow angle at risk of acute closure with normalIOP, or creeping angle closure with or without elevated IOP. Patients may present with what appears to be chronic OAG, but angle closure is subsequently discovered on gonioscopy. Acronyms IOP = intraocular pressure OAG = open-angle glaucoma PACG = primary angle-closure glaucomaAcronyms IOP = intraocular pressure OAG = open-angle glaucoma PACG = primary angle-closure glaucoma

5. Classification of angle closurebased on functional cause Acronyms AC IOL = anterior chamber intraocular lens ICE = iridocorneal-endothelialAcronyms AC IOL = anterior chamber intraocular lens ICE = iridocorneal-endothelial

6. Risk factors for development ofprimary angle closure Axial hyperopia Family history of angle closure Advancing age Female gender East Asian ethnicity Inuit ethnicity Latino ethnicity Shallow peripheral anterior chamber Short axial length eyes

7. Acute angle closure: Signs and symptoms Acronym IOP = intraocular pressureAcronym IOP = intraocular pressure

8. Narrow angle at risk of closure(angle-closure suspect) A patient would be considered an angle-closure suspect if he or she had iridotrabecular contact on gonioscopy without PAS, and without GON and VF damage. There are usually no symptoms associated with a narrow angle; however, intermittent angle closure is possible. Acronyms GON = glaucomatous optic neuropathy PAS = peripheral anterior synechiae VF = visual fieldAcronyms GON = glaucomatous optic neuropathy PAS = peripheral anterior synechiae VF = visual field

9. Narrow angle at risk of closure(angle-closure suspect) (cont�d) Signs of narrow angle at risk of closure include: Shallow peripheral anterior chamber and an open angle on gonioscopy. Trabecular meshwork, while still visible, is almost or partially occluded. The IOP is not elevated. Acronyms IOP = intraocular pressureAcronyms IOP = intraocular pressure

10. Creeping angle closure There are no symptoms associated with creeping angle closure. Signs include: normal or elevated IOP, PAS in portions of the angle, possible optic disc damage, and possible glaucomatous VF defects. Acronyms IOP = intraocular pressure PAS = peripheral anterior synechiae VF = visual fieldAcronyms IOP = intraocular pressure PAS = peripheral anterior synechiae VF = visual field

11. Diagnosis ofAngle Closure Glaucomas

12. Diagnosis ofangle closure glaucoma Diagnosis requires a detailed history and physical exam. History must include: whether the pupil has ever been pharmacologically dilated, medication history to elicit the use of medications that may dilate the pupil, such as those: with anticholinergic effects/side effects that counteract the iris sphincter muscle with sympathomimetic effects that work on the iris dilator muscle, that may cause anterior movement of the lens iris diaphragm (e.g., sulfonamides) family history of acute glaucoma or previous laser iridotomy in a first-degree relative, and personal history indicative of symptoms of previousintermittent attacks of angle closure.

13. Diagnosis ofangle closure glaucoma On examination, it is important to note: visual acuity refractive error pupil size and reaction presence of corneal edema anterior chamber depth centrally and peripherally presence of iris or angle new vessels indicative of neovascularization presence of anterior chamber inflammation IOP lens appearance Acronym IOP = intraocular pressureAcronym IOP = intraocular pressure

14. Diagnosis ofangle closure glaucoma Gonioscopy of both eyes is mandatory to assess the depth of the anterior chamber and the presence of PAS (compression gonioscopy with a Zeiss-type lens is very useful in differentiating PAS from apposition). Acronym PAS = peripheral anterior synechiaeAcronym PAS = peripheral anterior synechiae

15. Gonioscopy technique innarrow angles Recommendation Careful gonioscopy, performed under ideal conditions (dim ambient light, narrow light beam from the slit lamp, use of compression gonioscopy) is fundamental to assess the presence of angle closure in patients suspected of having narrow angles [Consensus].

16. Treatment of Angle-Closure Glaucomas

17. Treatment ofangle-closure glaucoma Treatment should be based on the type and cause of the angle closure, i.e.: primary acute angle closure, narrow angle with normal IOP, chronic angle closure, or secondary angle closure (which will further depend upon the particular underlying mechanism). Acronym IOP = intraocular pressureAcronym IOP = intraocular pressure

18. Treatment of primary acuteangle closure Upon diagnosis, agents to lower IOP are indicated, including: topical beta blockers topical miotics topical alpha-2 adrenergic agents topical and (or) systemic carbonic anhydrase inhibitors prostaglandins systemic hyperosmotics Acronym IOP = intraocular pressureAcronym IOP = intraocular pressure

19. Treatment of primary acuteangle closure (cont�d) Topical glycerol 100% (to achieve temporary clearing of the cornea when edema is present) may be useful. Corneal indentation (Anderson manoeuvre)1 with the tip of the Goldmann tonometer or Zeiss 4-mirror lens may be useful. Laser iridotomy should be performed when the cornea is clear. References Anderson DR. Corneal indentation to relieve acute angle-closure glaucoma. Am J Ophthalmol 1979;88:1091�3.References Anderson DR. Corneal indentation to relieve acute angle-closure glaucoma. Am J Ophthalmol 1979;88:1091�3.

20. Treatment of primary acuteangle closure (cont�d) In some instances, when the acute attack cannot be broken, peripheral laser iridoplasty may be helpful.1 In some instances, anterior chamber paracentesis,2 lens extraction,3 or surgical iridectomy4 may be useful. Laser iridotomy to the fellow eye is indicated to prevent an attack in the fellow eye (if it is similarly predisposed).5 References Lai JSM, Tham CCY, Chua JKH, et al. Laser peripheral iridoplasty as initial treatment of acute attack of primary angle closure: A long term follow up study. J Glaucoma 2002;11:484�7. Lam DSC, Lai JSM, Tham CCY, et al. Argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle closure glaucoma. Ophthalmology 2002;109:1591�6. Lam DSC, Chua JKH, Tham CCT, et al. Efficacy and safety of immediate anterior chamber paracentesis in the treatment of acute primary angle closure glaucoma. Ophthalmology 2002;109:64�70. Greve EL. Primary angle closure glaucoma: extracapsular extraction or filtering procedure? Int Ophthalmol 1988;12:157�62. Schwartz GF, Steinmann WC, Spaeth GL, Wilson RP. Surgical and medical management of patients with narrow anterior chamber angles: comparative results. Ophthalmic Surg 1992;23:108�12. Ang LP, Aung T, Chew PT. Acute primary angle closure in an Asian population. Long term outcome of the fellow eye after prophylactic laser peripheral iridotomy. Ophthalmology 2000;107:2092�6. Friedman DS, Chew PTK, Gazzard G, et al. Long term outcomes in fellow eyes after acute primary angle closure in the contralateral eye. Ophthalmology 2006;113:1087�91. Saw SM, Gazzard, Friedman DS. Interventions for angle closure glaucoma. An evidence based update. Ophthalmology 2003;110:1869�79.References Lai JSM, Tham CCY, Chua JKH, et al. Laser peripheral iridoplasty as initial treatment of acute attack of primary angle closure: A long term follow up study. J Glaucoma 2002;11:484�7. Lam DSC, Lai JSM, Tham CCY, et al. Argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle closure glaucoma. Ophthalmology 2002;109:1591�6. Lam DSC, Chua JKH, Tham CCT, et al. Efficacy and safety of immediate anterior chamber paracentesis in the treatment of acute primary angle closure glaucoma. Ophthalmology 2002;109:64�70. Greve EL. Primary angle closure glaucoma: extracapsular extraction or filtering procedure? Int Ophthalmol 1988;12:157�62. Schwartz GF, Steinmann WC, Spaeth GL, Wilson RP. Surgical and medical management of patients with narrow anterior chamber angles: comparative results. Ophthalmic Surg 1992;23:108�12. Ang LP, Aung T, Chew PT. Acute primary angle closure in an Asian population. Long term outcome of the fellow eye after prophylactic laser peripheral iridotomy. Ophthalmology 2000;107:2092�6. Friedman DS, Chew PTK, Gazzard G, et al. Long term outcomes in fellow eyes after acute primary angle closure in the contralateral eye. Ophthalmology 2006;113:1087�91. Saw SM, Gazzard, Friedman DS. Interventions for angle closure glaucoma. An evidence based update. Ophthalmology 2003;110:1869�79.

21. Treatment of narrow anglewith normal IOP Laser iridotomy is effective as a preventive measure in patients at moderate to high risk of experiencing an angle closure attack.1,2 An occludable angle would include: those with any degree of appositional closure, or when more than 180� of trabecular meshwork cannot be visualized with proper gonioscopic maneuvers. When the trabecular meshwork can be visualized for 360�, but the approach is very narrow and therefore felt to be at risk for closure, consideration should also be given to performing an iridotomy. Acronym IOP = intraocular pressure References Ang LP, Aung T, Chew PT. Acute primary angle closure in an Asian population. Long term outcome of the fellow eye after prophylactic laser peripheral iridotomy. Ophthalmology 2000;107:2092�6. Friedman DS, Chew PTK, Gazzard G, et al. Long term outcomes in fellow eyes after acute primary angle closure in the contralateral eye. Ophthalmology 2006;113:1087�91. Acronym IOP = intraocular pressure References Ang LP, Aung T, Chew PT. Acute primary angle closure in an Asian population. Long term outcome of the fellow eye after prophylactic laser peripheral iridotomy. Ophthalmology 2000;107:2092�6. Friedman DS, Chew PTK, Gazzard G, et al. Long term outcomes in fellow eyes after acute primary angle closure in the contralateral eye. Ophthalmology 2006;113:1087�91.

22. Laser iridotomy � prophylaxisagainst acute angle closure Recommendation Laser peripheral iridotomy should be performed in patients with narrow angles at risk for an attack of acute angle closure [Level 1B1,2]. References Ang LP, Aung T, Chew PT. Acute primary angle closure in an Asian population. Long term outcome of the fellow eye after prophylactic laser peripheral iridotomy. Ophthalmology 2000;107:2092�6. Friedman DS, Chew PTK, Gazzard G, et al. Long term outcomes in fellow eyes after acute primary angle closure in the contralateral eye. Ophthalmology 2006;113:1087�91. References Ang LP, Aung T, Chew PT. Acute primary angle closure in an Asian population. Long term outcome of the fellow eye after prophylactic laser peripheral iridotomy. Ophthalmology 2000;107:2092�6. Friedman DS, Chew PTK, Gazzard G, et al. Long term outcomes in fellow eyes after acute primary angle closure in the contralateral eye. Ophthalmology 2006;113:1087�91.

23. Treatment ofchronic angle closure Angle closure becomes chronic when permanent PAS develop. Once the pupil block component has been resolved by laser iridotomy, the IOP control is achieved by the same protocol as with chronic open-angle glaucoma. Acronyms IOP = intraocular pressure PAS = peripheral anterior synechiae Acronyms IOP = intraocular pressure PAS = peripheral anterior synechiae

24. Treatment of secondary angle closure Treatment is aimed at the specific etiology, e.g.: In lens-induced mechanisms, lensectomy may be indicated. In neovascularization, intravitreal anti-VEGF medication may help cause regression of the fibrovascular membrane. Acronym VEGF = vascular endothelial growth factorAcronym VEGF = vascular endothelial growth factor

25. Laser iridotomy �suspected pupillary block Recommendation Laser peripheral iridotomy should almost always be considered to remove the pupil block component in angle closure. It is even indicated in suspected cases of angle closure due to posterior mechanisms or plateau iris appearance in order to eliminate any possible pupillary block component. It is not indicated in cases secondary to anterior mechanisms such as angle neovascularization, iritis with PAS, iridocorneal-endothelial syndrome or epithelial down growth, as pupil block is not typically a factor in these situations [Consensus]. Acronym PAS = peripheral anterior synechiaeAcronym PAS = peripheral anterior synechiae

26. Neovascular Glaucoma

27. Neovascular glaucoma Neovascular glaucoma is a common form of secondary non-pupil block anterior-mechanism glaucoma. The most common inciting factors are: posterior segment ischemia due to central retinalvein occlusion, or diabetes mellitus. These lead to anterior segment iris and angle new vessel formation. The angle new vessels form a fibrovascular membrane, which contracts to create PAS and angle closure. Acronym PAS = peripheral anterior synechiae Acronym PAS = peripheral anterior synechiae

28. Treatment ofneovascular glaucoma Treatment is aimed at controlling the cause of the new vessels: by PRP, and possibly intraocular injection of anti-VEGF medication. IOP is controlled by the usual protocol as for open-angle glaucoma. If there is significant visual potential, filtering surgery is often required. If there is minimal visual potential, cycloablation is useful.1 Acronyms IOP = intraocular pressure PRP = panretinal laser photocoagulation VEGF = vascular endothelial growth factor Reference Iliev ME, Gerber S. Long-term Outcome of trans-scleral laser cyclophotocoagulation in refractory glaucoma. Br J Ophthalmol 2007;91:1631�5.Acronyms IOP = intraocular pressure PRP = panretinal laser photocoagulation VEGF = vascular endothelial growth factor Reference Iliev ME, Gerber S. Long-term Outcome of trans-scleral laser cyclophotocoagulation in refractory glaucoma. Br J Ophthalmol 2007;91:1631�5.

29. Ciliary Block Glaucoma

30. Ciliary block glaucoma Ciliary block glaucoma (malignant glaucoma or aqueous misdirection) is a rare cause of secondary non-pupil block posterior-mechanism glaucoma. It may occur after intraocular surgery of any kind, and may even occur after a laser iridotomy. It is likely due to ciliary body rotation and aqueous misdirection posteriorly. It may occur in phakic, pseudophakic or aphakic eyes.

31. Treatment ofciliary block glaucoma Initial treatment includes: laser iridotomy to minimize any potential pupil block component, as well as maximal cycloplegia with atropine.1 Acute treatment includes: topical beta blockers topical and (or) systemic carbonic anhydrase inhibitors prostaglandins, alpha-2 adrenergic agents systemic hyperosmotics Reference Chandler PA, Simmons RJ, Grant WM. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol 1968;66:2495�502. Reference Chandler PA, Simmons RJ, Grant WM. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol 1968;66:2495�502.

32. Treatment of ciliary blockglaucoma (cont�d) If the attack cannot be broken: in phakic eyes: a vitrectomy is indicated in pseudophakic or aphakic eyes: an attempt at Nd:YAG laser lysis of the anterior hyaloid and posterior capsule (hyaloidotomy or vitreolysis) may avoid a vitrectomy1 Reference Epstein DL, Steinert RF, Puliafito CA. Neodymium-YAG laser therapy to the anterior hyaloid in aphakic malignant (ciliovitreal block) glaucoma. Am J Ophthalmol 1984;98:137�43.Reference Epstein DL, Steinert RF, Puliafito CA. Neodymium-YAG laser therapy to the anterior hyaloid in aphakic malignant (ciliovitreal block) glaucoma. Am J Ophthalmol 1984;98:137�43.

33. Aqueous misdirection syndrome Recommendation Ciliary block (aqueous misdirection syndrome) must be considered in any patient with postoperative shallow anterior chamber with elevated or normal IOP [Consensus]. Acronym IOP = intraocular pressureAcronym IOP = intraocular pressure