Description

• Glaucoma is a progressive decline in vision from damage to the optic nerve and is usually associated with elevated intraocular pressure (IOP) in the eye. Angle-closure is a mechanical blockage of the trabecular meshwork (TM) by the peripheral iris.
• In primary angle-closure (PAC), there is an anatomic predisposition with no identifiable secondary pathologic condition.
• In secondary angle-closure, there is an identifiable pathologic cause, such as iris neovascularization or an enlarged cataractous lens.
• Angle-closure can be classified as the following:
  • Primary angle-closure suspect (PACS) is >180 degrees of iridotrabecular contact (ITC) but no evidence of TM or optic nerve damage
  • PAC is >180 degrees of ITC with peripheral anterior synechiae (PAS) or elevated IOP but with no optic neuropathy.
  • Primary angle-closure glaucoma (PACG) is PAC with glaucomatous optic neuropathy.
  • Acute primary angle-closure (APAC) or acute angle-closure crisis (AACC) is when the angle is occluded with symptomatic high IOP. It is a medical emergency requiring prompt treatment.
  • Chronic angle-closure (CAC) may develop after APAC in which synechial closure persists. It can also develop when the angle gradually closes and the angle function becomes progressively compromised leading to a slow rise in IOP. Vision loss may be the presenting complaint because of the asymptomatic nature of the condition.

Geriatric Considerations
Increased risk with age and cataracts

Pregnancy Considerations
Majority of IOP-lowering medications are within class C, and the risk of adverse effects to the fetus must be balanced with risk of vision loss in the mother.

Epidemiology

• Female sex. PAC is 2 to 4 times more common in women than in men. Women tend to have smaller anterior segments and shorter axial lengths.
• More likely in those of Inuit and East or South Asian descent

Prevalence
The prevalence of PACG in patients >40 years varies depending on race and ethnicity. The prevalence is 0.1–0.2% in blacks, 0.1–0.6% in whites, 0.3% in the Japanese, 0.4–1.4% in other East Asians, and 2.1–5.0% in the Inuit. The burden of PACG is greater in Asian countries.

Etiology and Pathophysiology

• PAC happens when iris touches the TM in the anterior chamber angle. ITC causes obstruction of aqueous humor outflow through the TM, which causes elevation in IOP. Prolonged ITC can cause scarring, with formation of PAS.
• Most common underlying mechanism of angle-closure is pupillary blockage of the aqueous flow from posterior to anterior chamber. This causes increase in pressure in the posterior chamber as compared to the anterior chamber. The buildup of pressure in the posterior chamber leads to anterior bowing of the iris and closing of the angle.
  • One of the most important factors in closing the angle in an anatomically predisposed eye is dilation of the pupil. Dilation leading to closure of the angle may occur as a result of a variety of causes including darkness, emotion, and medications that can cause the pupil to dilate. Pupillary block is maximal when the pupil is in the mid-dilated position.
• Plateau iris syndrome is an atypical configuration of the anterior chamber angle that can result in acute or chronic PAC. Angle-closure in plateau iris is most often caused by anteriorly positioned ciliary processes that narrow the anterior chamber recess by pushing the peripheral iris forward. A component of pupillary block is often present.

Genetics
First-degree relatives have a 1–12% increased risk in whites; 6 times greater risk in Chinese patients with positive family history

Risk Factors

• Age >50 years
• Female gender
• Family history of angle-closure
• Hyperopia
• Anterior positioned lens
• Drugs that can induce angle-closure by dilating the pupil include:
  • Adrenergic agonists (albuterol, phenylephrine), anticholinergics (oxybutynin, atropine), antihistamines, antidepressants including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), and cocaine
• Drugs that can induce angle-closure by causing a uveal effusion include:
  • Topiramate and other sulfonamides

General Prevention

• Routine eye exam with gonioscopy for high-risk populations
• Prophylactic laser peripheral iridotomy (LPI) may be considered in PACS patients for preventing PACG.
• Argon laser peripheral iridoplasty for plateau iris syndrome

Commonly Associated Conditions

• Cataract
• Hyperopia