Primary Angle-Closure and Angle-Closure Glaucoma

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 ophthalmologists 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 recommendations 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 encouraged to produce an updated English edition. The new evidence about the high prevalence of angle-closure in Asians further supports 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 structural defects of the optic nerve head or when visual field defects are found.

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

Preface
By Svend Vedel Kessing and John Thygesen

Introduction
Aims And Methods
Detection of Primary Angle-closure (PAC)
Limbal Chamber Depth Measurement (LCD)
Methodology
Sources of Error

Diagnostic Methods in PAC
Axial Chamber Depth Measurement (ACD)
Methodology
Optical Pachymetry
Ultrasonic or Laser Based Chamber Depth Measurement
Laser Scanning Pachymetry (Visante Oct System)
Sources of Error
Gonioscopy
Introduction
Goniolenses and Their Uses
Posner’s 4-mirror Indentation Lens
Goldmann’s Gonioscopy Lens

Gonioscopy Methods with PAC
Chamber Angle: Classification and Definitions
Standardised PAC Gonioscopy Methodology
Start the Examination with the Posner Lens 4-mirror Lens
Continuation with Goldmann’s Gonioscopy Lens
Gonioscopy Findings
Normal Anatomy of the Chamber Angle
Glaucoma Pathology in the Chamber Angle
Provocation Test
Dark-room Test – Prone Position
Ultrasound Biomicroscopy (UBM)

Main Classification of PAC
Introduction
Main Classification and Methods of Classification

Main Groups and Subclassification of PAC
Group I: PAC with Pupil Block
Pathophysiology and Pathogenesis
Detection and Diagnosis
Subclassification with Specific Treatment and Case
Histories
YAG-laser Iridotomy: Evaluation
YAG-laser Iridotomy in General
Group II: PAC with Plateau Iris
Pathophysiology and Pathogenesis
Detection and Diagnosis
Subclassification with Specific Treatment and Case
Histories
Argon-laser Iridoplasty: Evaluation
Argon-laser Iridoplasty in General
Group III: PAC Mixed Group (I+II)
Pathophysiolology and Pathogenesis
Detection and Diagnosis
Subclassification with Specific Treatment and Case Reports
YAG-laser Iridotomy/argon-laser Iridoplasty: Evaluation
YAG-laser Iridotomy/argon-laser Iridoplasty In General

Treatment Procedures with PAC
Principles of Treatment with Acute PAC I, II and III
Treatment of Acute PAC I, II and III (Previously “Acute Glaucoma”)
YAG-laser Iridotomy
Indications
Contraindications
Technique
Argon-laser Iridoplasty
Indications
Relative Iridoplasty Indications
Contraindications
Technique
Fistulating Operation
Indication
Complications
Prevention of Post-operative Hyperfistulation
Post-operative Treatment

References
Rights of illustrations
Index