Ординатура / Офтальмология / Английские материалы / Shields Textbook of Glaucoma, 6th edition_Allingham, Damji, Freedman_2010

Plateau iris has traditionally been included among the primary angle-closure glaucomas largely because of an incomplete understanding of the mechanism of angle closure (1, 2 and 3). Later evidence suggests that an anterior position of the ciliary body may cause the angle closure (113, 114 and 115). (This condition is considered in more detail in Chapter 17.)

DIFFERENTIAL DIAGNOSIS

The sudden onset of pain, redness, and blurred vision, which characterizes the acute angle-closure attack, may also be seen with other forms of glaucoma, creating a differential diagnostic problem. Open-Angle Glaucomas

Open-angle forms of glaucoma may occasionally manifest as an acute attack, especially when associated with events such as inflammation or hemorrhage. These cases are usually readily distinguished from acute forms of angle-closure glaucoma on the basis of the gonioscopic examination results and associated findings. However, in the eye with an elevated IOP and a narrow anterior chamber angle, it may be difficult to distinguish

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between pupillary block glaucoma and open-angle glaucoma with narrow angles. A thymoxamine test has been suggested for this situation (116). Unlike cholinergic miotics, which can lower IOP by opening a closed angle or by reducing resistance to trabecular outflow, thymoxamine, an a-adrenergic blocker, produces miosis by relaxation of the dilator muscle without effecting outflow through cyclotropia. As a result, topical thymoxamine, 0.5%, can often open a narrow or appositionally closed angle and lower the IOP in angle-closure glaucoma, but it cannot alter the pressure in an eye with open-angle glaucoma. Another approach to distinguishing between closedand openangle glaucoma is to perform a laser iridotomy, which relieves the pressure elevation in a pure angle-closure case, but additional measures will be required if an open-angle component is present.

Angle-Closure Glaucomas with Associated Abnormalities

There are many forms of angle-closure glaucoma with associated abnormalities, which may present even more difficult diagnostic problems, especially when the initiating event is posterior to the lens-iris diaphragm, where early detection can be difficult. The following are some of the ocular disorders that may lead to these forms of angle closure (details of these conditions are considered in subsequent chapters): plateau iris (see Chapter 17), central retinal vein occlusion (Chapter 19), ciliary body swelling, inflammation, or cysts (Chapter 17), ciliary block (malignant) glaucoma (Chapter 26), posterior segment tumors (Chapter 21), contracting retrolental tissue (Chapter 18), scleral buckling procedures and panretinal photocoagulation (Chapter 26), nanophthalmos (Chapter 14), corneal thickening and exfoliation syndrome (Chapter 15.)

MANAGEMENT

The details regarding drugs and surgical procedures used in the treatment of pupillary block glaucoma are considered in Section III of this textbook. The present discussion is limited to the general approach and basic concepts of management.

Medical Therapy

Although most eyes with acute, subacute, or chronic pupillary block glaucoma are managed surgically, it is desirable to first bring the glaucoma under medical control. An acute attack constitutes a medical emergency, and it should be approached in two stages: reduction of the IOP and relief of the angle closure.

Reduction of Intraocular Pressure

Miotic therapy is frequently ineffective when the IOP is high, presumably because of pressure-induced ischemia of the iris, which leads to paralysis of the sphincter muscle (77, 78 and 79). For this reason, the first line of defense is to administer drugs that will promptly lower the IOP. In many cases, oral or intravenous carbonic anhydrase inhibitors, topical ß-adrenergic blockers, a 2-adrenergic agonists, and

prostaglandin analogues can lower the pressure sufficiently to allow effective miotic therapy to open the angle (117, 118 and 119). In especially difficult cases, hyperosmotic agents may be used to help in the initial pressure reduction. They may be given orally as glycerol or isosorbide, if available, or if the

patient is too nauseated to tolerate oral medication, intravenous mannitol or urea may be given. Topical carbonic anhydrase inhibitors should probably be avoided because they can exacerbate or potentiate corneal edema, which may make laser treatment more challenging.

Relief of Angle-Closure Glaucoma

After the IOP has been reduced, a miotic is instilled to break the pupillary block and open the anterior chamber angle. A single drop of pilocarpine approximately 1 to 3 hours after administration of acetazolamide or timolol has been reported to effectively break the angle-closure attack (117, 119). This is also safer than copious use of pilocarpine, because it reduces the chances of drug toxicity. The concentration of pilocarpine does not appear to be important in this situation, and a low dosage of a 1% to 2% solution is preferable. a-Adrenergic antagonists, such as thymoxamine, have theoretical advantages over pilocarpine, because the mechanism of miosis is relaxation of the dilator muscle, which may allow effective pupillary constriction even when the IOP is elevated (120, 121). However, other investigators have not found thymoxamine alone to be effective in the treatment of angle-closure glaucoma (122).

Surgical Management

After the IOP has been brought under control medically or all efforts at medical control have been exhausted, the surgeon is faced with two decisions: when to operate and what procedure to use. These considerations have been influenced greatly by the replacement, in most cases, of incisional iridectomy with laser iridotomy.

When to Operate

In the days of incisional iridectomy when the elevated pressure could not be controlled medically, Chandler and Grant (123) advised considering surgery within the next few hours, especially if the vision was failing. However, the risks of incisional surgery are considerably higher under these circumstances, and mechanical techniques to lower the IOP before surgery may prove helpful. For example, indentation of the central cornea for several 30-second intervals, by using a blunt instrument such as a cotton-tipped applicator, may lower the pressure and occasionally break the attack by forcing aqueous from the central to the peripheral anterior chamber (Fig. 12.13) (124). Even with a laser iridectomy, it may be helpful to lower the IOP first to allow clearing of corneal edema. In any case, the safest approach to medically unresponsive cases is to proceed with the iridotomy. When an iridotomy cannot be achieved because of corneal edema, laser pupilloplasty or peripheral iridoplasty may break the attack (125, 126). An alternative strategy is to use topical glycerin drops, to osmotically clear the cornea. This can work well but can be painful when applied to the ocular

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surface; thus, before its instillation, a topical anesthetic should be applied. Yet another effective strategy to clear the cornea is to perform an anterior chamber paracentesis. This can be done by using a short 27- G or 30-G needle, with the bevel pointing anteriorly. The surgeon should enter the eye anterior to the limbus so that the needle tip will be between the iris and corneal endothelium, avoiding inadvertent damage to the iris or lens (127). A paracentesis typically results in rapid clearing of the cornea, and after the attack is broken laser iridotomy should be performed.

Figure 12.13 Corneal indentation with a soft instrument, such as a cotton-tipped applicator, may lower the IOP during an acute angle-closure attack by forcing aqueous from the central to the peripheral anterior chamber (arrows), thereby temporarily opening the chamber angle and reestablishing aqueous outflow (124).

If the IOP does respond to medical therapy, the eye should be re-examined gonioscopically to determine the mechanism of the pressure reduction. An open anterior chamber angle without compressive gonioscopy suggests that the angle-closure attack has been broken. In this situation, there is less urgency about when surgical intervention should be performed. In the days of incisional surgical iridectomy, some surgeons preferred to wait 1 or 2 days for the inflammation to subside. With laser iridotomy, however, there is no advantage in waiting unless marked iritis or corneal edema is present. In one longterm study of 116 cases, a delay in treatment detrimentally affected the final outcome (128). If the gonioscopic examination reveals that the angle is still closed despite medical lowering of the IOP, the pressure reduction may be caused by the drug-induced reduction of aqueous production or vitreous volume, and the angle-closure might not have been relieved. Because the high pressure may recur as the effects of these medications begin to wear off, there is even more urgency in proceeding promptly with the laser iridotomy and, if necessary, incisional surgery (as detailed in the next section).

What Operation to Use

The eye with pupillary block glaucoma typically responds well to a peripheral iridotomy, and the initial procedure of choice in nearly every case is a laser iridotomy. One study compared 50 eyes treated with incisional iridectomy or laser iridotomy to 64 treated medically and found that the former group had a greater number of improved anterior chamber configurations, a lower incidence of peripheral anterior synechiae, and a greater reduction in the need for glaucoma medications (129). Studies of anterior ocular segment configuration before and after iridotomy, using the Scheimpflug imaging technique, revealed a significant widening of the anterior chamber angle and a straightening of the iris contour, but found no significant change in the position of the anterior lens surface (130, 131).

Follow-up studies indicate that many eyes treated with an iridotomy alone will eventually require medication to control chronic pressure elevation, and some will need filtering surgery (132, 133, 134, 135, 136 and 137). Factors associated with the need for additional treatment include the duration of the angle-closure attack and a history of intermittent, spontaneously resolved angle-closure episodes (132, 137). These factors relate to the amount of permanent damage to the anterior chamber angle, which

sometimes correlates with the extent of gonioscopically visible peripheral anterior synechiae.

Even if compressive gonioscopy reveals partial synechial closure of the anterior chamber angle, it is best to proceed first with the laser iridotomy, because this has been shown to control the pressure in many cases of chronic angle-closure glaucoma (107). If the iridotomy does not restore a normal IOP, the eye is then treated with medication or filtering surgery if required. Caution must be taken when performing filtering surgery (and an incisional surgical iridectomy) on eyes with angle-closure glaucoma because of the increased risk of malignant (ciliary block) glaucoma (138) (see Chapter 26). Care must also be taken with the prolonged use of topical corticosteroids after laser or incisional surgery in these patients, because a high percentage will have steroid-induced IOP elevation after an attack of angle-closure glaucoma (139, 140).

Prophylactic peripheral iridotomy for the fellow eye is generally recommended at the same sitting or within a few days of an attack of pupillary block glaucoma. Several large studies have shown that approximately 50% to 75% of the patients who develop angle closure in one eye will have an attack in the fellow, unoperated eye within 5 to 10 years despite miotic prophylaxis (141, 142), whereas such an attack is rare after an iridectomy. Because the attack in the fellow eye usually occurs in the first year after the initial event (143), the prophylactic procedure should be done promptly. Rare exceptions include a deeper anterior chamber in the fellow eye due to anisometropia, pseudophakia, aphakia, and a dislocated lens. Some surgeons have suggested that fellow eyes with negative provocative test results might be followed closely without surgery. However, with the relative safety of laser iridotomy, a prophylactic procedure in all highrisk fellow eyes appears to be prudent.

Lensectomy and implantation of a posterior chamber intraocular lens for patients with acute and chronic angle closure may offer successful IOP control and improve vision. One randomized trial compared early phacoemulsification cataract surgery with laser peripheral iridotomy in 62 Chinese patients with acute angle closure in whom the attack had been aborted with medical treatment (144). Early phacoemulsification was more effective than peripheral iridotomy in preventing IOP rise. After 18 months, mean IOP in the cataract surgery group

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was significantly lower (12.6 ±1.9 mm Hg) than in the iridotomy group (15.0 ± 3.4 mm Hg); the former group also required significantly fewer medications than the latter to maintain an IOP no higher than 21 mm Hg (0.03 ± 0.18 vs. 0.90 ± 1.14). High presentin g IOP of greater than 55 mm Hg was an added risk factor for subsequent IOP rise. No eyes had significant (vision-threatening) complications. In another, nonrandomized trial comparing phacoemulsification cataract surgery with iridotomy in patients with acute or chronic angleclosure glaucoma, the cataract surgery group had significantly greater IOP lowering, compared with the laser iridotomy group, at 6 months postoperatively (145). Endothelial cell counts did not differ postoperatively between the groups.

Lensectomy, implantation of a posterior chamber intraocular lens, and trabeculectomy with use of an antimetabolite can also be helpful options in the management of patients with chronic angle-closure glaucoma and cataract. Two randomized trials found that phacotrabeculectomy with the use of mitomycin C provided superior IOP control compared with phacoemulsification alone, regardless of whether the IOP was medically controlled before surgery (146, 147). However, in both trials, the phacotrabeculectomy group experienced more postoperative complications.

Lensectomy with lysis of peripheral anterior synechiae is yet another beneficial option in patients with chronic angleclosure glaucoma, provided that the procedure is performed within 6 to 12 months of an acute attack (148).

Cataract extraction appears to be helpful in each of the aforementioned scenarios by removing pupillary block and deepening the anterior segment, thus improving access to the peripheral angle. When after an acute attack lensectomy is most appropriate and whether the procedure should be combined with filtration surgery are currently unclear, however. An approach favored by many surgeons is to proceed with cataract surgery, with or without goniosynechialysis, in patients with a visually significant cataract or uncontrolled IOP. Phacotrabeculectomy with mitomycin C can be used when a patient has probably

had peripheral anterior synechial closure for more than 1 year, or in the presence of moderate-to- advanced optic nerve damage. Further studies should help clarify how and when to use these approaches in the management of this challenging patient population.

KEY POINTS

Angle-closure glaucoma is more common than chronic open-angle glaucoma in some Inuit and Asian populations.

A predisposing factor to angle closure is a narrow anterior chamber angle, which has a familial tendency and is associated with increasing age and hyperopia.

An angle-closure attack may be precipitated in a predisposed individual by factors that induce mydriasis, such as dim illumination, emotional stress, and drugs.

The basic mechanism of pupillary block glaucoma is a functional block between the lens and iris, which obstructs aqueous flow from the posterior to the anterior chamber, resulting in increased pressure in the posterior chamber, forward bowing of the peripheral iris, and closure of the anterior chamber angle.

The clinical presentation of angle-closure glaucoma may be that of an acute attack with severe pain, marked conjunctival hyperemia, a cloudy cornea, and profound visual loss, or as a subacute attack with a dull ache, slight blurring of vision, and colored halos around lights. Still other cases may be chronic and typically asymptomatic.

Patients at risk for angle-closure glaucoma should avoid taking over-the-counter decongestants, antihistamines, or other medications with warnings against use in glaucoma.

Treatment usually begins with aggressive medical therapy to lower the IOP and relieve the angle closure, followed by a peripheral iridotomy to prevent future attacks. Argon laser iridoplasty or anterior chamber paracentesis can also help resolve an acute attack. The ideal role and optimal timing of cataract surgery in patients with angle-closure glaucoma remain to be determined.

If IOP is still elevated after laser iridotomy, additional mechanisms should be considered, such as peripheral anterior synechiae formation, a combined mechanism (i.e., underlying open-angle or exfoliation glaucoma), or plateau iris.

Lens extraction with IOL placement alone or in combination with surgical goniosynechialysis or trabeculectomy can be an effective treatment for chronic angle-closure glaucoma.

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