Page 92 - NAME OF CONDITION: REFRACTIVE ERRORS

A carefully done goniosopy for diagnosis of angle closure is crucial and helps in follow up
and management of these patients. Preferably, indentation gonioscopy is done in

patients suspected for angle closure to differentiate appositional from synechial closure.
It is first done in dim illumination with a short slit beam avoiding the pupil and then on
indentation with a bright light. Excessive compression on the gonioscope and/ or excess
light entering the pupil may artifactually open up the angle. Careful assessment of the
angle structures with their exact anatomic documentation along with iris contour, iris
processes, areas of peripheral anterior synechiae with pigmentation of the angle should
ideally be done.

Optic nerve head and visual fields assessment:
Undilated disc assessment (if possible prior to laser peripheral iridotomy) with a +78/90
Dioptre lens under a slit lamp biomicrosope along with a dilated fundus examination
with nerve fiber layer and optic nerve head assessment.

b) Investigations:
Automated perimetry (preferably Humphrey 24-2 SITA Standard/ Octopus G1 test) form
the gold standard tests for the diagnosis and follow up of the glaucoma patient. In
patients with advanced visual field losses 10-2 or macular threshold test on Humphrey
may be required. Since visual fields may have a learning curve, it is preferable to have
two visual fields with replicable defects to establish a reliable baseline. Serial
stereoscopic disc photographs/disc drawings also form an important additional modality

to follow up a patient.
c) Treatment:
Guidelines to therapy:

Treatment for angle closure revolves around intraocular pressure control, assessment
and therapy directed to the control of the angle and angle closure, prevention and
treatment for acute primary angle closure, preventing progression of glaucoma and thus
aiming to preserve a patient’s vision and quality of life.
(1) Control of intraocular pressure:
Antiglaucoma medications are prescribed to control IOP for short term either before
definitive therapy by laser or surgery and following the same for residual IOP elevation
in the long term. All major classes of drugs can be used as for open angle glaucomas
such as beta blockers, alpha agonists, carbonic anhydrase inhibitors, prostaglandin
analogues, cholinergic agents and hyperosmotic agents can be used depending on their
tolerability, side effects and contraindications. However Pilocarpine is usually

contraindicated in lens induced and retro lenticular mechanisms as it may cause forward
movement of iris lens diaphragm and shallowing of chamber angle. At low doses,
Pilocarpine can be used for relieving residual appositional closure after laser iridotomy
or iridoplasty in plateau iris and angle closure patients.

2) Angle control:
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