Secondary closed-angle glaucoma

• Summary
• Classification
• Causes of secondary closed angle glaucoma
• Secondary Closed-Angle Glaucoma with Pupillary block
• Lens related glaucoma (phacomorphic glaucoma)
• Subluxated lens
• Uveitic glaucoma
• Secondary Closed Angle Glaucoma without pupillary block
• Uveitic glaucoma
• Iridocorneal endothelial syndrome
• Intraocular tumour
• References
• Author(s)

Summary

Secondary angle-closure glaucoma occurs when the angle between the iris and the cornea is narrow or closed, as a result of another disease process in the eye.

Classification

Secondary closed angle glaucoma can be divided into two types, 1) with pupillary block, and 2) without pupillary block.

In cases of pupillary block, there is no movement of aqueous through the pupil because of 360 degree posterior synechiae between the iris and the lens, known as ‘seclusio pupillae’.

In secondary angle closure glaucoma without pupillary block, angle closure can be due to either a) contraction of an inflammatory, haemorrhagic, or vascular membrane in the angle, resulting in peripheral anterior synechiae, or b.) forward displacement of the lens-iris diaphragm, often associated with ciliary body swelling and anterior rotation.

Causes of secondary closed angle glaucoma

Source: Kanski

Secondary Closed-Angle Glaucoma with Pupillary block

Lens related glaucoma (phacomorphic glaucoma)

Pathogenesis:

This condition is precipitated by an intumescent cataractous lense, i.e. a cataract that results in swelling congestion of the lens. Equitorial growth of the lens with age results in a slackening of the suspensory ligament, and anterior movement of the lens. This results in increased iridolenticular contract, resulting in pupillary block and iris bombé.

Features:

Presents similarly to PACG with a shallow anterior chamber and mid dilated pupil, with a cataract.

Treatment:

Initial medical treatment is similar to that of acute PACG. Miotics are typically not used, as they tend to shift the lens anteriorly increasing iris-lens apposition. Systemic hyperosmotic agents (e.g. mannitol) are more commonly used than in PACG. The definitive treatment is cataract extraction, once IOP has been normalized and the eye is quiet.

Subluxated lens

Pathogenesis:

Blunt ocular trauma in eyes with weak zonules (e.g. in pseudoexfoliation or homocystinuria) can result dislocate the lens. Congenitally small lens are also at greater risk of dislocation, such as in Weill-Marchesani syndrome.

Features:

A lens dislocated into the anterior chamber will usually be clinically evident. Acute pupillary block may cause a sudden severe elevation of IOP.

Treatment:

The IOP is initially reduced with osmotic agents. Treatment needs to be given urgently as prolonged lenticulocorneal contact can result in permanent endothelial damage. The patient should remain supine position with the pupil dilated, as an attempt to reposition the lens to the posterior chamber, following which a miotic can be used with caution. Definitive treatment is surgical lens extraction, with replacement by an anterior chamber, iris, or sclerally fixated IOL.

Uveitic glaucoma

Pathogenesis:

Posterior synechiae extending for 360 degrees (seclusio pupillae) obstructs aqueous flow from the posterior to anterior chamber. This results in increased pressure in the posterior chamber, resulting in anterior bowing of the peripheral iris (an iris bombé). This leads to shallowing of the anterior chamber and apposition of the iris to the trabeculum and peripheral cornea. Note that uveitic glaucoma can also occur without pupillary block (see below), and can also result a secondary open angle glaucoma.

Features:

Slit lamp biomicroscopy shows seclusio pupillary, iris bombé, and a shallow anterior chamber. Gonioscopy shows angle closure from iridotrabecular contact.

Secondary Closed Angle Glaucoma without pupillary block

Uveitic glaucoma

Pathogenesis:

Chronic anterior uveitis results in the deposition of inflammatory cells and debris in the angle. Contraction of this material then pulls the peripheral iris over the trabeculum, causing gradual and progressive synechial angle closure.

Features:

The anterior chamber is deep, but gonioscopy shows extensive angle closure by peripheral anterior synechiae.

Iridocorneal endothelial syndrome

Pathogenesis:

ICE syndrome commonly results in an open angle glaucoma due to trabecular obstruction, as detailed in our secondary open angle glaucoma article, however eventually contraction of the proliferating tissue results in closure of the angle.

Intraocular tumour

Pathogenesis:

Anterior displacement of the iris-lens diaphragm may occur in an eye with ciliary body melanoma, or a large tumour of the posterior segment. Note that, intraocular tumours may also cause a secondary open angle glaucoma through trabecular block (insert link).

References

1. Bowling, Brad. Kanski’s Clinical Ophthalmology: A Systematic Approach 2016. Open WorldCat, http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=2029294.
2. Lee JY, Kim YY, Jung HR. Distribution and characteristics of peripheral anterior synechiae in primary angle-closure glaucoma. Korean J Ophthalmol. 2006 Jun;20(2):104-8
3. Iris Bombe | Columbia Ophthalmology, https://www.columbiaeye.org/education/digital-reference-of-ophthalmology/glacucoma/angle-closure-glaucoma/iris-bombe. Accessed 11 July 2022

Author(s)

Dr Sara Memon

Sara is the Co-Founder of Ophtnotes. She is a doctor who graduated from UCL Medical School in London. She won the Allen Goldsmith Prize in Ophthalmology. Sara is also the co-founder of PAMSA: an organisation linking doctors and medical students of Pakistani origin. She’s especially passionate about teaching and education, having presented a workshop she designed herself at the 2019 Annual GMC Conference.