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PRIMARY ANGLE-CLOSURE GLAUCOMA
Primary angle-closure is the synechial or appositional closure of the anterior chamber angle secondary to multiple mechanisms resulting in raised intraocular pressure and structural changes in the eyes.
Iridotrabecular contact is the hallmark of primary angle-closure  and the most commonly identified sign which indicates that treatment is required.
It is defined by at least 180 degrees of iridotrabecular contact together with an elevated intraocular pressure or peripheral anterior synechiae or btoh
Primary angle-closure glaucoma is the presence of glaucomatous optic neuropathy.

Definition

Primary Angle-Closure (PAC)

  • Synechial or appositional closure of the anterior chamber angle secondary to multiple mechanisms resulting in raised intraocular pressure (IOP) & structural changes in the eyes but w/o glaucomatous optic neuropathy
    • Iridotrabecular contact (ITC) is the hallmark of PAC & the most commonly identified sign which indicates that treatment is required
    • Defined by at least 180 degrees of ITC together w/ an elevated IOP or peripheral anterior synechiae (PAS) or both

Pathophysiology

Mechanisms of Primary Angle-Closure Glaucoma

  • Mechanisms responsible for angle closure are defined in terms of anatomic location of obstruction to aqueous flow
  • Important to determine the mechanism involved since initial management is directed at the underlying disease
  • Pupillary Block Mechanism
    • Accounts for approx 75% of cases of primary angle-closure
    • Aqueous flow from the posterior chamber through the pupil to the anterior chamber is blocked, resulting in the peripheral iris bowing forward & coming into contact w/ the trabecular meshwork &/or peripheral cornea
  • Obstruction at the Level of Iris &/or Ciliary Body (“Plateau Iris”)
    • Results from variations in iris & ciliary body anatomy that brings the peripheral iris into contact w/ the trabecular meshwork
    • Ciliary processes that are anteriorly positioned cause typical “iris plateau configuration” in which the iris plane is flat & the anterior chamber is not shallow axially
    • Characterized by a more anterior iris insertion, a thicker iris & a more anterior ciliary body position 
  • Other less frequent mechanisms include anomalies at the lens level, eg thicker, more anteriorly placed lens, & posterior to the lens (aqueous misdirection syndrome), eg forward movement of the lens iris diaphragm results in intraocular pressure (IOP) elevation

Signs and Symptoms

  • Most angle closures are asymptomatic until advanced
    • Specificity & sensitivity of symptoms for identifying angle closure are very poor, although symptoms such as redness, pain, halos, blurring of vision may help identify significant angle closure

Risk Factors

  • Demographic risk factors
    • Family history of angle closure (increases glaucoma risk 5-fold; 1st-degree relatives are at higher risk)
    • Older age
    • Female
    • Asian or Inuit descent
  • Ocular risk factors
    • Hyperopia
    • Shallow central anterior chamber depth
    • Shallow peripheral anterior chamber depth
    • Steep corneal curvature
    • Short axial length
    • Thick crystalline lens
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