terminology and guidelines for glaucoma ii - Kwaliteitskoepel
terminology and guidelines for glaucoma ii - Kwaliteitskoepel
terminology and guidelines for glaucoma ii - Kwaliteitskoepel
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4.4 - PRIMARY ANGLE-CLOSURE<br />
4.4.1 - PRIMARY ANGLE-CLOSURE (PAC)<br />
Angle-closure with plateau iris mechanism<br />
See FC X<br />
Medical treatment:<br />
Pupillary constriction to pull centripetally the peripheral iris.<br />
In plateau iris configuration, a modest pupillary constriction may prevent further angle-closure<br />
- pilocarpine 1%, aceclidine 2%, carbachol 0.75%<br />
- dapiprazole 0.5%, thymoxamine 0.5%<br />
Surgical treatment:<br />
- Peripheral laser iridoplasty stretches the iris <strong>and</strong> deepens the chamber angle.<br />
- Iridectomy or Iridotomy may be helpful only when plateau iris is combined with pupillary block<br />
mechanism<br />
Angle-closure with posterior aqueous misdirection<br />
See FC X<br />
Medical treatment<br />
- Parasympatholytics (atropine, scopolamine, cyclopentolate) may be useful as a prophylactic or curative<br />
regimen.<br />
- Aqueous production suppressants (see above) given orally <strong>and</strong>/or topically<br />
- Hyperosmotics (Ch. 4.3.1)<br />
Surgical treatment<br />
- A patent iridotomy must be present or, if not present, iridotomy should be per<strong>for</strong>med.<br />
- YAG laser vitreolysis/capsulotomy, especially in aphakia, pseudophakia.<br />
- Anterior vitrectomy, especially in aphakia, pseudophakia.<br />
- In selected cases lens/IOL extraction.<br />
4.4.1.1 - Acute angle-closure with pupillary block mechanism<br />
See FC XI<br />
Iridotomy or iridectomy is the preferred definitive treatment of acute angle-closure <strong>glaucoma</strong> with a pupillary<br />
block component.<br />
Medical treatment only serves to lower IOP, to relieve the symptoms <strong>and</strong> signs so that laser iridotomy or<br />
iridectomy is possible. The main principles of medical therapy aim at<br />
(1) withdrawal of aqueous from vitreous body <strong>and</strong> posterior chamber by hyperosmotics,<br />
(2) pupillary constriction to free the chamber angle, <strong>and</strong><br />
(3) reduction of aqueous production,<br />
ALL THE FOLLOWING THREE STEPS SHOULD BE IMPLEMENTED CONCURRENTLY<br />
• Reduction of aqueous production<br />
- acetazolamide 10 mg/Kg intravenously or orally.<br />
- topical alpha-2 agonists<br />
- topical betablockers<br />
Topical CAIs are not potent enough to break pupillary block.<br />
Ch. 4 - 9 EGS