CLINICAL MANAGEMENT GUIDELINES

Glaucoma (primary angle closure) (PACG)

Aetiology

Predisposing factors

Symptoms

Signs

Primary angle closure (PAC) is defined as appositional or synechial

closure of the anterior chamber angle.
It is caused by a variety of mechanisms although pupil block is
considered to be a key element in the pathogenesis of most cases of
PAC.
PAC is generally bilateral, although 90% of acute attacks are unilateral.
Patients with angle closure and those at risk of closure may be
categorized as follows:
PAC Suspect: is an eye with iridotrabecular contact (ITC) without
peripheral anterior synechiae (PAS) or raised IOP and normal discs and
visual fields
PAC: is an eye that has at least 180 degrees of ITC with PAS and/or
elevated IOP but no evidence of glaucomatous optic neuropathy or
secondary (physical or inflammatory) causes of angle closure
Primary Angle Closure Glaucoma (PACG): includes the above
features with evidence of glaucomatous optic neuropathy (disc changes
and/or visual field defect)
Anatomical
Associated with:
sex (F:M ratio 4:1)
ethnicity (e.g. East Asian descent)
short axial length (hypermetropia)
shallow AC (F>M)
increasing age (AC becomes shallower as lens thickness
increases)
small corneal diameter
Iatrogenic
Drug induced
Adrenergic agents e.g. phenylephrine
Drugs with anticholinergic effects e.g. tricyclic antidepressants
Drugs that may cause supraciliary effusion e.g. topiramate,
sulphonamides
Systemic drugs see Evidence Base
Surgery induced
Angle closure may follow a number of surgical procedures, for
example vitreo-retinal surgery with intraocular gas, especially in
aphakic eyes
Patients may be asymptomatic or they may present with sudden onset of
symptoms and signs typical of an acute angle closure attack:
Rapid progressive impairment of vision of one or both eyes
Ocular and periocular pain which can be severe
Nausea and vomiting
Ocular redness
50% of patients with an acute angle closure attack give history of
previous intermittent attacks, e.g. episodes of blurring of vision lasting 12 hours, associated with haloes around lights, eye ache or frontal
headache
The eye may appear normal (with the exception of a narrow angle, as
judged by the van Herick technique or by gonioscopy), however in an
acute attack the following signs may be present:

Glaucoma (primary angle closure) (PACG)

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Glaucoma (primary angle closure) (PACG)

Limbal and conjunctival vessels dilated, producing ciliary flush

Pupil fixed, semi-dilated, vertically elliptical
Corneal oedema
Shallow AC with peripheral irido-corneal contact (if angle can be
visualised)
High intraocular pressure (40-80mmHg)
AC flare and cells
Optic disc oedematous and hyperaemic
Grey/white anterior sub-capsular lenticular opacities
(Glaukomflecken): diagnostic of previous attacks
Differential diagnosis Neovascular glaucoma
Phakolytic glaucoma
Phakomorphic glaucoma
Acute anterior uveitis
Hypertensive uveitis
Cilio-lenticular block (malignant glaucoma)
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non-pharmacological
None
Acute PAC attack
Pharmacological
Prior to referral, commence first aid treatment with a drop of pilocarpine
2% in blue eyes and 4% in brown eyes. Where the IOP is 40mmHg or
higher and the patient is not vomiting, give a single dose of oral
acetazolamide (Diamox) 500mg. (NB: this may be hazardous in an
elderly frail patient.) Then refer as an emergency to Ophthalmologist. (In
view of potential unwanted effects of this treatment, patient should be
accompanied by a carer or relative.)
Suspect PAC/PAC/PACG
No pharmacological intervention
Management Category Acute Angle Closure attack
A2: first aid measures and emergency (same day) referral to
Ophthalmologist
PAC/PACG
A3: urgent (within one week) referral to Ophthalmologist; no intervention
Suspect PAC
A3 (modified): routine referral to Ophthalmologist; no intervention
Possible management by Ophthalmologist
Acute Angle Closure attack: treatment directed to breaking the pupil
block
Medical
miotics (e.g. gutt. pilocarpine 2-4%)
systemic agents (e.g. acetazolamide, glycerol)
topical antihypertensives (eg g timolol, g latanoprost)
Urgent interventions
anterior chamber paracentesis (occasionally used in advance of
peripheral iridotomy)
argon laser peripheral iridoplasty (occasionally used in advance
of peripheral iridotomy)
laser peripheral iridotomy
Glaucoma (primary angle closure) (PACG)
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Less urgent interventions
lens extraction (see Evidence Base)
Evidence base
Saw SM, Gazzard G, Friedman DS. Interventions for angle-closure
glaucoma: an evidence-based update. Ophthalmology 2003;110:1869-78
Authors conclusion
This review suggests that Laser Peripheral Iridotomy (LPI) should be
recommended for the treatment of affected and contralateral eyes of
AAC patients. In patients with PAC and insufficient treatment with LPI,
latanoprost eye drops may decrease IOP more than timolol. There is still
insufficient evidence about other interventions for the treatment of AAC
and PAC.
(See also: American Academy of Ophthalmology Glaucoma Panel.
Preferred Practice Pattern Guidelines: Primary Angle Closure. San
Francisco, CA: American Academy of Ophthalmology; 2010. Available
at: www.aao.org/ppp)
Friedman D, Vedula SS. Lens extraction for chronic angle-closure
glaucoma. Cochrane Database of Systematic Reviews 2006,
Issue 3. Art. No.: CD005555. DOI: 10.1002/14651858.CD005555.pub2.
Authors conclusions
There is no evidence from good quality randomized trials or nonrandomized studies of the effectiveness of lens extraction for chronic
primary angle-closure glaucoma.
Drug-induced acute angle closure glaucoma
Lachkar Y, Bouassida W
Current Opinion in Ophthalmology 2007, 18:129133
(The Oxford 2011 Levels of Evidence = 2)

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