PrimaryAngleClosure_def 20-06-2007 14:10 Pagina 1 Primary P r i m a r Angle-Closure and y A n g l Angle-Closure Glaucoma e - C l o s u r e a n d A n g l e - C l o s u r e G l a u c o m a S by Svend Vedel Kessing . V . K and John Thygesen e s s in g a n d J . T h y g e s e n 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 kkeessssiinngg--vvrrww..iinndddd ii 2200--66--22000077 1155::0000::4477 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 kkeessssiinngg--vvrrww..iinndddd iiii 2200--66--22000077 1155::0000::4477 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 kkeessssiinngg--vvrrww..iinndddd iiiiii 2200--66--22000077 1155::0000::4477 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 kkeessssiinngg--vvrrww..iinndddd iivv 2200--66--22000077 1155::0000::4477 Table of Contents V Complications 106 Prevention of Post-operative Hyperfistulation 107 Post-operative Treatment 107 References 109 Rights of illustrations 112 Index 113 kkeessssiinngg--vvrrww..iinndddd vv 2200--66--22000077 1155::0000::4488 VI Table of Contents kkeessssiinngg--vvrrww..iinndddd vvii 2200--66--22000077 1155::0000::4488 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. kkeessssiinngg--vvrrww..iinndddd vviiii 2200--66--22000077 1155::0000::4488 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 kkeessssiinngg--vvrrww..iinndddd vviiiiii 2200--66--22000077 1155::0000::4488 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 kkeessssiinngg..iinndddd 11 2200--66--22000077 1155::0044::2200