Original Article
ABSTRACT INTRODUCTION
Purpose: A prospective observational case series to assess Primary angle closure glaucoma (PACG) is common among
the prevalence of appositional angle closure in darkness the Chinese population.1,2 Recent studies have shown that a
among iridotomized Chinese eyes after acute primary angle large proportion of patients, after acute primary angle clo-
closure (APAC) with the use of both clinical methods and sure (APAC), develop an increase in intraocular pressure on
long-term follow up despite the presence of a patent laser
ultrasound biomicroscopy.
peripheral iridotomy (LPI).3 In many of these cases, medical
therapy fails and filtration surgery is required. The uncon-
Methods: Sixteen Chinese patients who had history of trolled intraocular pressure may be a result of trabecular
APAC and subsequent successful treatment with laser damage or peripheral anterior synechiae (PAS) formation.
peripheral iridotomy were examined. Fourteen additional The latter is likely to play an important role in the develop-
control subjects were studied. Gonioscopy and ultrasound ment of chronic angle closure even with the presence of a
biomicroscopic examination were performed in the dark. patent iridotomy. A patent peripheral iridotomy, which can
Gonioscopic appearance of the angle was assessed, and only eliminate the pupillary block mechanism of angle clo-
quantitative measurements of the angle from the ultrasound sure, may not be sufficient on its own to prevent the forma-
biomicroscopic images were taken. tion of PAS. It is now well known that there are various other
mechanisms of angle closure, namely, plateau iris, lens-
induced and mixed type.4 It has also been postulated that
Results: Of the APAC eyes 55.6% had appositionally closed
in Chinese eyes mixed mechanisms are involved in post-
angle clinically and in 38.9% only Schwalbe’s line was visi- iridectomy glaucoma.5,6 It is therefore reasonable to postu-
ble on gonioscopy. Ultrasound biomicroscopy confirmed late that, in addition to pupillary block, the above various
structurally different anterior segments between eyes with mechanisms can also lead to appositional angle closure,
APAC and the control eyes. In particular, the trabecular- which in turn may contribute to synechial angle closure and
ciliary-process distances were markedly different between the subsequent development of chronic angle closure. When
the two groups. a significant proportion of the angle is closed and the
intraocular pressure is subsequently raised, filtration surgery
Conclusion: This study documented a high prevalence of may be the only treatment for the control of intraocular
appositional closure in iridotomized eyes after APAC in pressure.
In this study, we examined the prevalence of appositional
Chinese patients. The anteriorly positioned ciliary body, as
angle closure in darkness among a group of patients with
documented in these cases by ultrasound biomicroscopy, is patent LPI after an attack of APAC. Theoretically, an eye
the likely mechanism of the angle crowding in this patient with a patent LPI is assumed to be free of pupil block.
population. However, the occurrence of intraocular pressure (IOP) rise
in iridotomized eyes during the dark-prone test and dark
Key words: appositional closure, ciliary body, patent iri- room provocative test have been observed by Hung.5,6
dotomy, prevalence. Mechanisms other than pupil block, including angle crowd-
Correspondence: Dr Barry YM Yeung, Department of Ophthalmology and Visual Science, The Chinese University of Hong Kong, Hong Kong Eye Hospital,
147K Argyle Street, Kowloon, Hong Kong, China. Email: ymyeung@ha.org.hk
Angle closure after iridotomy 479
ing, can be responsible for the IOP rise.5 In our study, the endothelium at a point 500 mm from the scleral spur perpen-
rationale behind examining patients under dark environment dicularly through the iris to the ciliary process. The IT was
is in line with Hung’s observation. Any residual appositional measured along this line. The IZD corresponds to the pos-
angle closure in these iridotomized eyes may possibly be terior chamber depth measured from the posterior iris surface
exaggerated and thus more readily detected along with to the first visible zonular fibre at a point just clearing the
mydriasis in response to darkness. Apart from clinical exam- cliary process. All these quantitative measurements were per-
inations, we also examined the eyes with ultrasound biomi- formed by a single well-trained operator (C.W.T.).
croscope (UBM) in the dark to help us understand the ANOVA test was used to verify that there was no signifi-
mechanisms of angle closure in Chinese patients. cant difference in the measurements taken from each quad-
rant within the same eye. A P-value of less than 0.05 was
considered significant. A characteristic image of the angle
METHODS from each eye was chosen for quantitative analysis. Plateau
Sixteen consecutive Chinese patients who had APAC (acute iris was defined clinically as the configuration of the periph-
symptomatic attack with raised IOP and with the angle eral iris in which the root angulates sharply forward and then
closed on gonioscopy) and underwent laser iridotomy in centrally.10 For the fellow eyes in the APAC cases, the diag-
both eyes from October 2000 to February 2001 were pro- nosis of glaucoma was formulated when at least two of the
spectively recruited at Hong Kong Eye Hospital to have followings were detected: intraocular pressure ≥ 22 mmHg
UBM examination of the eyes. Exclusion criteria were: (i) on presentation, glaucomatous optic disc abnormality and
cases of secondary angle closure, such as uveitis, iris neovas- glaucomatous visual field defects (Humphrey 24-2 program).
cularization, trauma or tumour; (ii) patients who were unable Chronic angle closure was defined as an eye condition in
to cooperate with the examination; (iii) eyes put on pilo- which acute attacks never occurred but PAS were detected.
carpine; and (iv) patients with history of previous intraocular
operation. Fourteen consecutive control patients (all
Chinese) of similar age and sex distribution were also pro-
RESULTS
spectively recruited from our general ophthalmic clinic There were 3 men and 13 women in the APAC group. There
around the same period. Informed consents were obtained in were 3 men and 11 women in the control group. The mean
all studied subjects. age of the patients in the APAC group was 69.8 ± 10.1 years.
All subjects had detailed ophthalmic examination includ- The mean age of the control group was 71.1 ± 6.7 years. Two
ing gonioscopy in the dark. Gonioscopy was performed with patients had bilateral acute attack. Therefore, there were 18
the Posner indentation gonioscope. The room lights were eyes with APAC and 14 fellow eyes. Of the fellow eyes, 12
switched off and only a narrow beam of light from the slit of them had no glaucoma and two had chronic angle closure
lamp was used. The patency of the LPI was assessed and glaucoma.
confirmed by retro-illuminatio and direct visualization of the Table 1 tabulates the gonioscopic appearance of the angle
lens. The angle of each quadrant of each eye was examined in the APAC eyes and the fellow eyes.
and the feature identified was recorded. The visible angle Gonioscopically, eyes of all patients in the APAC group
structure that occupied more than 180∞ was taken to repre- had the appearance of the iris root angulating sharply for-
sent that eye. ward and then centrally. Figure 1 shows the characteristic
Ultrasound biomicroscopy was performed with the com- double hump or sine wave sign on indentation that occurred
mercial model of the instrument (Paradigm Medical Indus- in most of the eyes. On gonioscopy, synchial closure was
tries, Salt Lake City, UT, USA) and with a 50 MHz found in 10 APAC eyes and 6 fellow eyes. The extent of PAS
transducer. UBM examination was performed with the was about 90∞ in 14 eyes and 180∞ in the other two (both
patient lying supine. The room was kept in darkness and only were APAC eyes).
illuminated by the monitor of the UBM machine. The We demonstrated no statistically significant difference in
patient was asked to fixate on a distant target with the fellow all the UBM parameters (TCPD, IT, IZD and ACD) between
eye to prevent accommodation. This had ensured that the
pupil size remained virtually constant and the angle config-
uration remained relatively unchanged. Under topical anaes- Table 1. Gonioscopic appearance of the angle in the acute pri-
thesia, a plastic eye-cup was used to separate the eyelids. mary angle closure (APAC) eyes and in the fellow eyes
Methylcellulose 2.5% was used as the coupling agent. Radial
scans of 12, 3, 6, 9 o’clock positions and an axial scan were Appearance of the angle APAC eyes Fellow eyes
n (%) n (%)
performed. Quantitative measurements of various parame-
ters, namely, the anterior chamber depth (ACD), iris-zonule Closed angle, Schwalbe’s line not 10 (55.6) 6 (42.9)
distance (IZD), trabecular-ciliary process distance (TCPD) visible
and iris thickness (IT), were performed. The parameters were Only Schwalbe’s line visible 7 (38.9) 7 (50)
Schwalbe’s line and non-pigmented 1 (5.6) 1 (7.1)
measured according to the method published by Pavlin
trabeculum visible
et al.7–9 TCPD was used to assess the position of the ciliary Total 18 (100) 14 (100)
body and was measured on a line extending from the corneal
480 Yeung et al.
the eyes with APAC and their fellow eyes (Table 2). When were statistically different (Table 4). Figures 2 and 3 show
comparing the eyes with APAC and the control group, all the characteristic UBM image of the angle. Figures 4 and 5
but the IT were statistically different (Table 3). When com- show the UBM image of the angle of a control eye for
paring the fellow eyes and the control group, all but the IT comparison. Concerning the type of angle closure in our
cases, one eye was type S (closure starting in the vicinity of
the Schwalbe’s line) and the rest were type B (closure starting
from the bottom of the angle recess).
DISCUSSION
Primary angle closure glaucoma is a heterogeneous entity. It
is often difficult to clinically classify the distinct types of
PACG with the use of indentation gonioscopy alone. UBM
is a very useful and important tool in identifying the different
characteristics in these angles. UBM also allows quantitative
measurements of distances between different structures.
These parameters have been proven to be very different in
the eyes with PACG and eyes in the normal population.9
In our series, there was no significant difference in any of
the parameters measured in the APAC eyes and in their
fellow eyes (Table 2). Thus, the fellow eyes are also at risk
of developing glaucoma, as documented in the literature.10,11
Figure 1. A gonioscopic picture showing double hump sign on An important difference between our normal control
indentation. cases and the APAC cases was the TCPD. This distance
Table 2. Comparison of quantitative measurements between the APAC eyes and the fellow eyes
ACD, anterior chamber depth; APAC, acute primary angle closure; IT, iris thickness.
Table 3. Comparison of quantitative measurements between the APAC eyes and the control group
ACD, anterior chamber depth; APAC, acute primary angle closure; IT, iris thickness; IZD, iris-zonule distance; TCPD, trabecular-ciliary
process distance.
Table 4. Comparison of quantitative measurements between the fellow eyes and the control group
ACD, anterior chamber depth; IT, iris thickness; IZD, iris-zonule distance; TCPD, trabecular-ciliary process distance.
Angle closure after iridotomy 481
ACKNOWLEDGEMENT
This study was supported in part by Action for Vision Eye
Foundation, Hong Kong.