eMedicine Specialties > Ophthalmology > Intraocular Pressure

Glaucoma, Angle Closure, Chronic: Treatment & Medication

Author: Robert Ritch, MD, Chief of Glaucoma Service, Surgeon Director, Professor, Department of Ophthalmology, New York Eye and Ear Infirmary
Coauthor(s): Clement CY Tham, BM BCh(Oxford), FRCS(Glasgow), FCOphth(HK), Professor, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong; Honorary Consultant, Department of Ophthalmology, Queen Mary Hospital, Hong Kong
Contributor Information and Disclosures

Updated: Jun 2, 2006

Treatment

Medical Care

It is important to recognize early stages of appositional angle-closure in the absence of PAS and to recognize deep, circumferential angle-closure. Laser iridotomy is indicated for all stages of CACG. Iridotomy will open those areas of the angle not involved by PAS and prevent further synechial closure.

Miotic treatment may enhance the development of CACG in the absence of an iridotomy. When miotic-induced angle-closure occurs, the approach to treatment should be determined by assessing the medications necessary to control the glaucoma. If a patient is taking dipivefrin, discontinuation may be enough to open the angle and allow the patient to remain on miotics, assuming that IOP remains under control. If the patient has been treated with miotics alone, substitution of aqueous suppressants may suffice. If the patient requires miotics for IOP control, then laser iridotomy is warranted.

If the angle remains appositionally closed or spontaneously occludable after laser iridotomy, argon laser peripheral iridoplasty (ALPI) is indicated to prevent progressive damage to the angle or further appositional and/or synechial closure of the angle. If, after iridoplasty, some of the angle still remains appositionally closed, low-dose pilocarpine, such as pilocarpine 2% at bedtime, often suffices to maintain the patency of the angle.

The level of IOP and the extent of glaucomatous damage determine the need for continued medical treatment after iridotomy. Treatment is similar to that of open-angle glaucoma. Repeated gonioscopy is necessary. The need for further surgery cannot be predicted from the level of initial IOP or the gonioscopic changes. Argon laser trabeculoplasty (ALT) has been reported both to be successful and unsuccessful after iridotomy in combined mechanism glaucoma; however, overall it has been found to be reasonably successful. If the pressure remains uncontrolled and glaucomatous damage develops, filtration surgery is indicated. An increased chance of developing malignant glaucoma is present following filtration surgery in patients who have had angle-closure glaucoma.

Surgical Care

Goniosynechialysis is a surgical procedure designed to physically strip PAS from the angle wall and to restore trabecular meshwork function. A paracentesis track is made into the anterior chamber, and the chamber is allowed to shallow slightly. Massage is performed at the limbus to force aqueous from the posterior chamber into the anterior chamber. A viscoelastic agent is injected, and the angle is visualized with direct gonioscope. An irrigating cyclodialysis spatula is used to separate a small segment of PAS with an anterior to posterior movement.

Goniosynechialysis is successful only if the synechiae have been present for less than 1 year. Although it has not become popular in the US, it has become popular in Asia, where promising results have been reported in both phakic and pseudophakic eyes. It is effective both alone and in conjunction with other surgical procedures. Argon laser peripheral iridoplasty can be used postoperatively to further flatten the peripheral iris and to prevent synechial reattachment. Complications include bleeding, iridodialysis, and marked inflammation.

Other surgical options for medically uncontrolled CACG may include cataract extraction by phacoemulsification with or without trabeculectomy and transscleral cyclophotocoagulation.

Consultations

Glaucoma specialist

Medication

The goal of pharmacotherapy is to reduce morbidity and to prevent complications.

Cholinergic agents

Considered the first step in the treatment of glaucoma. The DOC in this category is pilocarpine. Dosage and frequency of administration must be individualized.


Pilocarpine 1% to 8% (Akarpine, Ocusert P-40, Adsorbocarpine)

Directly stimulates cholinergic receptors in the eye, decreasing resistance to aqueous humor outflow.
Instillation frequency and concentration are determined by response. Individuals with heavily pigmented irides may require higher strengths.
If other glaucoma medication also is being used, at bedtime, use gtt at least 5 min before gel.
Patients may be maintained on pilocarpine as long as IOP is controlled and no deterioration in visual fields occurs.

Adult

1 or 2 gtt tid/qid

Pediatric

Not established

May be ineffective when used concomitantly with nonsteroidal anti-inflammatory agents

Documented hypersensitivity; acute inflammatory disease of anterior chamber

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in acute cardiac failure, peptic ulcer, hyperthyroidism, GI spasm, bronchial asthma, Parkinson disease, recent MI, urinary tract obstruction, and hypertension or hypotension

More on Glaucoma, Angle Closure, Chronic

Overview: Glaucoma, Angle Closure, Chronic
Differential Diagnoses & Workup: Glaucoma, Angle Closure, Chronic
Treatment & Medication: Glaucoma, Angle Closure, Chronic
Follow-up: Glaucoma, Angle Closure, Chronic
References
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Further Reading

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Keywords

CACG, chronic angle-closure glaucoma, plateau iris, miotic-induced angle-closure glaucoma, combined mechanism glaucoma, mixed mechanism glaucoma, peripheral anterior synechiae, PAS, anterior chamber angle

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Contributor Information and Disclosures

Author

Robert Ritch, MD, Chief of Glaucoma Service, Surgeon Director, Professor, Department of Ophthalmology, New York Eye and Ear Infirmary
Robert Ritch, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Ophthalmological Society, Chinese American Medical Society, International College of Surgeons, New York Academy of Medicine, and New York Academy of Sciences
Disclosure: Nothing to disclose.

Coauthor(s)

Clement CY Tham, BM BCh(Oxford), FRCS(Glasgow), FCOphth(HK), Professor, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong; Honorary Consultant, Department of Ophthalmology, Queen Mary Hospital, Hong Kong
Disclosure: Nothing to disclose.

Medical Editor

Andrew I Rabinowitz, MD, Consulting Staff, Department of Ophthalmology, Barnet Dulaney Perkins Eye Center
Andrew I Rabinowitz, MD is a member of the following medical societies: Aerospace Medical Association, American Academy of Ophthalmology, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Martin B Wax, MD, Clinical Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Ophthalmology Research and Development, Head, Ophthalmology Discovery Research, Alcon Labs, Inc
Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Society for Neuroscience
Disclosure: Alcon Labs Salary Employment

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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