Primary Angle Closure 1
What is the difference of "appositional" and "synechial", and how can you distinguish this on exam?
Appositional: transient or intermittent
Synechial: permanent
Indentation gonio
Name at least 4 symptoms and 4 ocular findings in acute angle closure.
Symptoms: eye pain, headache, blurred vision, rainbow colored lights, n/v.
Eye findings: high IOP, mid dilated sluggish or irregular shaped pupil, k edema, congested episcleral vessels, mild AC flare/cell, shallow peripheral AC
How can angle closure occur in aphakic or pseudophakic patients?
Vitreous can block pupil
How do steroids lead to increased IOP?
Induction of physical and mechanical changes in the microstructure of the trabecular meshwork (TM), inhibition of proteases and TM endothelial phagocytosis, and deposition of substance in the TM
Glaucoma and ocular hypertension are risk factors for developing what retinal pathology?
CRVO
Distinguish Primary Angle Closure Suspect, Primary Angle Closure, and Primary Angle Closure Glaucoma.
PACS: iridoTM contact >180 deg, but no evidence of TM abnormalities, elevated IOP, or optic nerve damage
PAC: iridoTM contact >180 deg, but with elevated IOP or PAS
PACG: PAC + glaucomatous optic neuraopathy
What causes the rainbow colored halos in acute angle closure?
Corneal epithelial edema
Describe how a scleral buckle can lead to angle closure.
Shallows the angle, accompanied by choroidal effusion and anterior rotation of the ciliary body leading to a flattening of the peripheral iris. Vortex vein compression can lead to chordal effusions and increased episcleral venous pressure.
What group of viruses can classicaly cause uveitis associated with elevated IOP?
Herpes
What is the most common cause of secondary open angle glaucoma?
Name at least 3 classes of systemic medications that may cause angle closure.
Allergy / cold medicine (ephedrine, diphenhydramine), bronchodilators (ipra/tiotropium), SSRIs, TCAs, antispasmodics for bladder stuff (oxybutynin), muscle relaxants, anti nausea (promethazine)
Drugs with adrenergic or anticholinergic activity.
How does an LPI work in treating PAC? What is an alternative surgical procedure?
Relieves pupillary block and reduce further potential for PAS formation.
Lens extraction.
At what anatomical line does PAS generally do not cross, and why?
Bonus 100: And what condition has PAS passing this line?
Schwalbe's line, PAS does not row over healthy corneal endothelium.
Bonus: iridocorneal endothelial syndrome / ICE
In angle recession glaucoma, describe the location of the tear between what two things?
Tear bewteen the longitudinal and circular muscular fibers in the ciliary body.
How can one help distinguish phacolytic and phacoantigenic glaucoma on exam?
The presence of KP likely points towards phacoantigenic glaucoma.
Name at least 3 anatomic findings associated with increased risk of angle closure. Bonus 100 points for each additional finding.
Shallow AC, thick lens, increased anterior curvature of lens, short AL, small corneal diameter, small radius of corneal curvature, increased iris thickness
How does plateau iris configuration lead to angle closure?
Anteriorly positioned ciliary processes narrowing the AC recess by pushing the peripheral iris forward.
How can aqueous misdirection be distinguished from pupillary block on exam?
In pupillary block, the peripheral AC is shallow with iris bombe, but central AC is usually not shallow.
In aqueous misdirection, the whole lens iris diaphragm is shifted anteriorly leading to a shallow central AC in addition to shallow peripheral AC.
What can be found in the AC in patients with Schwartz Matsuo sydrome?
Outter segments of photo receptors
Describe Possner-Schlossman Syndrome.
Episodes of unilateral IOP spikes with low grade AC inflammation.
What is glaucomaflecken? What causes it? And what is the name of his trusty scribe?
Small anterior sub capsular lens opacities. Caused by lens epithelial necrosis due to elevated IOP.
Jonathan
Where does synechial formation start in plateau iris? Bonus 200: how does this differ in pupillary block induced angle closure?
Starts at the scleral spur and progresses posteriorly.
Bonus: starts posteriorly and progresses anteriorly.
What are the 3 variants of ICE and what are the differences?
Chandler: minimal iris atrophy/corectopia
Essential iris atrophy: severe iris atrophy, Heterochromia, corectopia
Cogan- Reese: less severe iris atrophy, but also with tan pedunculated pigmented iris lesions
Describe lens particle glaucoma.
Retained lens material after surgery or trauma obstructs TM
In patients with Fuchs heterochromic iridocyclitis, what can happen during paracentesis placement during cataract surgery?
Bonus house: what is this sign called?
AC hemorrhage due to fine vessels crossing over the angle (Amsler sign).