Table Of ContentPrimaryAngleClosure_def 20-06-2007 14:10 Pagina 1
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Kugler Publications, Amsterdam, The Netherlands
Table of Contents I
Primary angle-closure
and
angle-closure glaucoma
by
Svend Vedel Kessing and John Thygesen
Kugler Publications/The Hague/The Netherlands
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II Table of Contents
ISBN 10: 90-6299-211-0
ISBN 13: 978-90-6299-211-9
Distributors:
For the U.S.A. and Canada:
Pathway Book Service
4 White Brook Road
Gilsum, WH 03448
U.S.A.
email: [email protected]
For all other countries:
Kugler Publications
P.O. Box 20538
1001 NM Amsterdam, The Netherlands
Telefax (+31.20) 68 47 788
website: www.kuglerpublications.com
© Copyright 2007 Kugler Publications
All rights reserved. No part of this book may be translated or
reproduced in any form by print,
photoprint, microfilm, or any other means without prior written
permission of the publisher.
Kugler Publications is an imprint of SPB Academic Publishing
bv, P.O. Box 20538
1001 NM Amsterdam, The Netherlands
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Table of Contents III
TABLE OF CONTENTS
Preface VII
By Svend Vedel Kessing and John Thygesen
Introduction 1
Aims And Methods 1
Detection of Primary Angle-closure (PAC) 7
Limbal Chamber Depth Measurement (LCD) 7
Methodology 7
Sources of Error 10
Diagnostic Methods in PAC 11
Axial Chamber Depth Measurement (ACD) 11
Methodology 13
Optical Pachymetry 13
Ultrasonic or Laser Based Chamber Depth Measurement 14
Laser Scanning Pachymetry (Visante Oct System) 15
Sources of Error 16
Gonioscopy 16
Introduction 16
Goniolenses and Their Uses 17
Posner’s 4-mirror Indentation Lens 18
Goldmann’s Gonioscopy Lens 23
Gonioscopy Methods with PAC 25
Chamber Angle: Classification and Definitions 25
Standardised PAC Gonioscopy Methodology 29
Start the Examination with the Posner Lens 4-mirror
Lens 30
Continuation with Goldmann’s Gonioscopy Lens 32
Gonioscopy Findings 32
Normal Anatomy of the Chamber Angle 32
Glaucoma Pathology in the Chamber Angle 41
Provocation Test 45
Dark-room Test – Prone Position 45
Ultrasound Biomicroscopy (UBM) 46
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IV Table of Contents
Main Classification of PAC 49
Introduction 49
Main Classification and Methods of Classification 50
Main Groups and Subclassification of PAC 55
Group I: PAC with Pupil Block 55
Pathophysiology and Pathogenesis 55
Detection and Diagnosis 57
Subclassification with Specific Treatment and Case
Histories 58
YAG-laser Iridotomy: Evaluation 67
YAG-laser Iridotomy in General 69
Group II: PAC with Plateau Iris 70
Pathophysiology and Pathogenesis 71
Detection and Diagnosis 73
Subclassification with Specific Treatment and Case
Histories 75
Argon-laser Iridoplasty: Evaluation 80
Argon-laser Iridoplasty in General 83
Group III: PAC Mixed Group (I+II) 84
Pathophysiolology and Pathogenesis 84
Detection and Diagnosis 84
Subclassification with Specific Treatment and Case Reports 85
YAG-laser Iridotomy/argon-laser Iridoplasty: Evaluation 91
YAG-laser Iridotomy/argon-laser Iridoplasty In General 93
Treatment Procedures with PAC 95
By J. Thygesen
Principles of Treatment with Acute PAC I, II and III 95
Treatment of Acute PAC I, II and III (Previously “Acute
Glaucoma”) 96
YAG-laser Iridotomy 100
Indications 100
Contraindications 100
Technique26 101
Argon-laser Iridoplasty 102
Indications 103
Relative Iridoplasty Indications 104
Contraindications 104
Technique 104
Fistulating Operation 105
Indication 106
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Table of Contents V
Complications 106
Prevention of Post-operative Hyperfistulation 107
Post-operative Treatment 107
References 109
Rights of illustrations 112
Index 113
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VI Table of Contents
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Preface VII
PREFACE
The objective of this book is to offer the general ophthalmologists a
clinical comprehensive and practical guidance manual for primary
angle-closure and primary angle-closure glaucoma to be used in
the daily clinical work.
Already in the nineteen seventies our Danish colleague, Poul
Helge Alsbirk documented the exceptional high prevalence of
angle-closure glaucoma among the Eskimo or Inuit population
in Greenland, a North-Atlantic part of Denmark. As Danish oph-
thalmologists ever since have been responsible for the diagnostics
and therapy of primary angle-closure (PAC) and primary angle
closure glaucoma (PACG) among these patients, this has led to
a profound clinical experience and a growing knowledge of the
complicated nature of this entity. We have experienced that the
sub-clinical asymptomatic, “creeping” angle closure is a common
type and early detection and prevention therefore necessary, just
as in open-angle glaucoma. Further that different mechanisms
and stages of PAC need different treatments and that a new, more
differentiated and objectively based classification and terminology
consequently has to be developed. To practice these recommen-
dations we have learnt to use a number of standardised, clinical
diagnostic methods.
To support the Danish ophthalmologists a guidance manual for
primary angle-closure in Danish was published 2003 based on our
long clinical experience, the present evidence based literature and
conferences on glaucoma.
As the guidelines in Danish were very well received we were en-
couraged to produce an updated English edition. The new evidence
about the high prevalence of angle-closure in Asians further sup-
ports an English edition. The point that early angle-closure may be
cured and the fact that the world-wide visual disability from this
disease is almost equivalent to open-angle glaucoma emphasizes
the “urgent need” of improving the angle-closure management.
The word “glaucoma” is now only used in the presence of struc-
tural defects of the optic nerve head or when visual field defects
are found.
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VIII Preface
Acknowledgment should be given to our Danish colleagues Poul
Helge Alsbirk, Erik Krogh and Lisbeth Serup for their advice and
guidance of crucial importance.
A special thank goes to Pfizer Denmark, who published the first
edition in Danish and sponsored the translation from Danish into
English with an unrestricted educational grant.
Copenhagen May 2007
Svend Vedel Kessing and John Thygesen
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Introduction 1
INTRODUCTION
AIMS AND METHODS
In February 1997, the Danish Glaucoma Society published a book
of guidance describing the classification, diagnostics and treat-
ment of primary open-angle glaucoma (POAG)21. The present book
has been published as an attempt to provide a similar guidance
manual for primary angle-closure glaucoma and its prelimi-
nary stages. The first edition in Danish was already published
in 2003 and the contents of the present book in English are the
same, with few updates.
In 1998, the European Glaucoma Society published their first
edition of Guidelines for Glaucoma and in 2003 the second edi-
tion, in which the subject of primary angle-closure glaucoma was
also treated. However, the present book suggests a more radical,
well-defined and systematic treatment procedure, which in
certain substantial areas proposes innovative thinking, to a great
extent based on the personal clinical experience and attitude of
the authors.
Throughout the book, the term ‘glaucoma’ will only be used when
the observed development stage of angle-closure is incurable, i.e in
connection with permanently increased intraocular pressure (IOP)
due to peripheral anterior synechiae (PAS), latent glaucoma;
and increased IOP together with the classical structural/functional
glaucoma defects, manifest glaucoma. In principle, this is simi-
lar to POAG21. Furthermore, the Anglo-Saxon term ‘primary
angle-closure’ (PAC) will be used.
Due to these terminological changes, a successfully treated case
of acute PAC without subsequent complications in the form of
permanently increased eye pressure or structural/functional glau-
coma defects will not, as was previously the case, be classified
as being ‘acute glaucoma’. Obviously, this is an undisputed
advantage to the patient in question since it provides the oppor-
tunity of declaring that the patient has been cured and does not
indeed have glaucoma. By not labelling the patient as having a
glaucoma diagnosis, the quality of life of the patient will remain
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