acute angle closure glaucoma
Introduction
Introduction to acute angle-closure glaucoma Acute angle-closure glaucoma (acuteangle-closureglaucoma) is an eye disease that causes a sharp increase in IOP due to a sudden closure of the anterior chamber angle. The pathogenesis is still not clear. Often accompanied by obvious eye pain, decreased vision, ipsilateral migraine, nausea, vomiting and other symptoms, if not properly treated in time, can be blind in a short period of time. The anterior chamber is extremely shallow, but the room water flashes, but it is lighter. Due to the increased permeability of the iris, the protein in the plasma leaks into the aqueous humor. At the beginning, there is no floating cells in the aqueous humor, and there may be brown floats in the future. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: phlebitis cavernous sinus thrombosis
Cause
Causes of acute angle-closure glaucoma
1. Internal cause
Anatomical and physiological factors.
(1) variability and genetic defects in the normal range of anatomical structure: such as small eyeball, small cornea, hyperopic eye, shallow anterior chamber, and high pleat red film at the end, making the anterior chamber shallow angle narrow, leading to aqueous humor Discharge obstacles.
(2) Physiological changes: pupillary block, narrow anterior chamber angle, moderate dilation of the pupil is an important condition, coupled with the increase of age, the crystal grows with age, gradually close to the pupil edge, so that the iris and crystal The pupillary block is formed, and the posterior chamber pressure is higher than the anterior chamber pressure, and the corneal sclera elasticity is weakened, which has no compensatory ability to increase the pressure. Therefore, the peripheral iris is pushed forward, the iris bulges to close the angle of the anterior chamber, and the intraocular pressure is increased. .
2, external factors
(1) Emotional hormones: central nervous system dysfunction, cerebral cortical excitation inhibition disorder, inter-brain intraocular pressure regulation central disorder, vascular motor neurological disorders make pigmented membrane hyperemia, edema, sympathetic excitation, dilated pupils, can make iris roots To Zhoulian, blocking the corner of the room.
(2) The point is scattered and frozen, the dark room is tested or the movie is watched. If the TV is too long, the pupil is dilated, and the angle of the corner is blocked, resulting in an increase in intraocular pressure.
Increased intraocular pressure can cause a series of pathological changes in the eyeball.
1, acute stage: manifested as intraocular circulatory disorders and tissue edema, corneal edema, iris ciliary body congestion, edema and even exudation, expansion of the bulbar conjunctiva, retinal vasodilation, congestion and even bleeding.
In the early stage of acute angle-closure glaucoma, the iris matrix is highly congested and edematous, and the iris root is displaced forward and in close contact with the trabecular meshwork, making the anterior chamber angle narrower or completely occluded. During this period, the anterior chamber angle is only in contact with each other, and the machine has not yet occurred. After the acute phase sign is removed, the symptoms of the acute phase can be relieved. If the iris root and the trabecular meshwork are in contact for a long time, the iris matrix and the anterior trabecular meshwork are fibrotic and degenerated, resulting in permanent adhesion. The occluded anterior chamber will no longer be open, the stent is also deformed by compression, and the corner of the chamber permanently loses the function of aqueous drainage.
2, chronic stage: manifested as tissue degeneration or atrophy, such as corneal degeneration caused by bullous keratitis, iris ciliary body atrophy and pigmentation, retinal optic atrophy and typical papillary glaucoma cup formation.
Primary glaucoma is mostly bilateral, which can occur successively and has a family history of genetics.
Prevention
Acute angle closure glaucoma prevention
Acute angle-closure glaucoma is a common emergency condition. Timely diagnosis and treatment are very important, and comprehensive and thoughtful care is a key step in treatment. The main points of care are as follows:
1. Psychological care, glaucoma patients are generally irritable and irritated, sensitive to environmental changes, should be patiently explained to the patient, attitude and embarrassment, behave in a civilized manner, and explain to the patient that glaucoma acute episodes are closely related to emotions, requiring patients to maintain good Psychological state, comfortable mood, regular life, and treatment.
2. Closely observe the reaction of patients after medication, frequently apply miotic agents, sometimes sweating, asthma, dizziness, at this time should be taken to keep warm, sweat in time, report to the doctor for treatment, local medicine, the drug should be close to the outside The ankle is compressed and the lacrimal sac is compressed to reduce the absorption of pilocarpine through the nasolacrimal duct. Patients taking acetazolamide should pay attention to the interval of 6-8 hours per administration, and take it after meals, and give the same dose at the same time. Sodium bicarbonate, regular urine checkup, a small number of patients drinking water, not more than 300ml each time, so as not to stimulate the increase of intraocular pressure, not with the use of acidic drugs, such as vitamin C, patients with low back pain, urinary difficulties, hand and foot Numbness, drugs should be stopped, hematuria should appear, renal pain should be reported to the physician for timely treatment, 20% mannitol has strong and rapid dehydration and diuresis, but pay attention to observe the patient's complexion, pulse, breathing, blood pressure changes, venipuncture A shot of blood, to avoid extravasation or leakage of the drug, causing local tissue swelling and pain.
3. The treatment environment should be quiet to ensure adequate sleep for the patient. The pillow should be properly raised when sleeping, so as to prevent the scleral venous pressure from increasing and causing an increase in intraocular pressure.
4. Postoperative patients often need to use dilated drugs for reactive rainbow eye disease or shallow anterior chamber. Instead of surgery, they need to use miotic drugs. In this case, check seven pairs to avoid medication errors.
5. Repeat the above precautions to the patient at the time of discharge, and insist on reviewing the clinic.
Complication
Acute angle-closure glaucoma complications Complications venous cavernous sinus thrombosis
Some complicated with septic phlebitis, cavernous sinus thrombophlebitis.
Symptom
Acute angle-closure glaucoma symptoms Common symptoms There is red blood level ciliary congestion under the anterior chamber. Physiological blind spots expand paralysis Hong Kong dystrophy dystrophic fundus changes purulent secretions nausea conjunctival hyperemia
Clinical manifestations are divided into 6 phases according to the disease development process:
1. Pre-clinical stage
No symptoms, but need treatment. Including the following two situations:
(1) There was an acute attack at one glance, but there was no history of seizures in the other eye, but it has the characteristics of shallow anterior chamber and narrow anterior chamber. It may be sooner or later.
(2) There is a family history of acute primary angle-closure glaucoma, shallow anterior chamber, narrow angle of the anterior chamber, no history of seizures, but positive test.
2. Prodromal stage
(1) Symptoms: mild eye pain, vision loss, rainbow vision, accompanied by ipsilateral migraine, nasal root and eyelid soreness and nausea.
(2) Signs: mild ciliary congestion, slight decrease in corneal transparency, slightly shallow anterior chamber, mild pupil dilation, and mild IOP.
Symptoms and signs are mild in this period. Most of the above symptoms occur after mood swings or fatigue, and often occur in the evening or at night when the pupils are dilated. After getting to the light or after sleep, the pupils shrink and the symptoms can be relieved. The duration is generally short, and the interval is longer, usually after 1 to 2 hours, the symptoms can completely subside. After multiple episodes, the duration is gradually prolonged, and the interval is shortened, and the symptoms gradually increase to the acute episode. There are also a few cases that directly manifest as acute attacks without a prodromal period.
3. Acute attack stage
The onset is urgent, most or all of the anterior chamber angle is closed, and the IOP suddenly rises.
(1) Symptoms: severe eye pain, extreme vision loss, ipsilateral migraine, eyelid pain, nausea, vomiting, and even increased body temperature, pulse speed and so on.
(2) Signs:
1) Conjunctival ciliary or mixed hyperemia with conjunctival edema.
2) Corneal epithelial edema, foggy turbidity, loss of consciousness, brown deposits on the posterior wall of the cornea.
3) The anterior chamber is extremely shallow, and there may be flash of aqueous humor, but it is lighter. Due to the increased permeability of the iris, the protein in the plasma leaks into the aqueous humor. At the beginning, there is no floating cells in the aqueous humor, and there may be brown floats in the future.
4) Iris edema, crypt disappears, such as long duration of high intraocular pressure, can make 1 ~ 2 radial iris occlusion, resulting in iris ischemic infarction in the corresponding area, and iris fan-shaped atrophy, pigment released from pigment epithelium The particles can settle on the posterior wall of the cornea, the surface of the iris, and the surface of the ciliary body.
5) The pupil is half open and has a vertical oval shape. This is because the high intraocular pressure causes the pupil sphincter to paralyze, and there may be adhesion after the pupil, but it is generally not serious.
6) Under the anterior capsule of the lens, there may be a turbid white-spotted border, which is called glaucoma plaque, which is often located at the lens joint and does not occur in the area covered by the iris. Glaucoma spots are permanently turbid and are covered by new lens fibers. Therefore, the depth of glaucoma in the lens can be estimated from the time after the acute attack, and sometimes the small glaucoma can be resolved.
7) IOP is obviously elevated, mostly above 50mmHg, even up to 80mmHg or higher.
8) Corner closure: The anterior chamber corner mirror is attached to the trabecular meshwork. If the duration of acute attack is short, the angle of the eye can be opened or limited. If the duration is long, a permanent corner adhesion is formed.
9) Fundus: Because of corneal epithelial edema, it is often necessary to drip glycerin to make the cornea temporarily clear before you can see the fundus. The nipple is congested, there is an arterial pulsation, the retinal vein is dilated, and occasionally a little retinal hemorrhage occurs.
4. Intermittent stage
After acute exacerbation of glaucoma, after drug treatment or natural remission, the anterior chamber is reopened, IOP returns to normal, and the condition is temporarily relieved. It is called intermittent or remission. Because the pathogenic factors such as pupillary block are not relieved, it will be relapse.
(1) Symptoms: No discomfort.
(2) Signs: If there is no permanent damage left in the acute attack, there is no positive result except for the shallow anterior chamber and the narrow angle. The diagnosis can only be determined on the basis of medical history and provocation tests.
5. Chronic stage
Symptoms in the acute phase were not all relieved, and the prolonged transition to chronic, often due to excessive closure of the angle of the corner, permanent adhesion of the surrounding iris and trabecular meshwork.
(1) Symptoms: There are still mild eye pain, eye swelling, and unclear vision in the early stage of the chronic phase. Later, the symptoms disappear or only mild eye swelling.
(2) Signs:
1) There are still signs of acute exacerbation in the early stage of this period, but the degree is lighter. Afterwards, the congestion is regressed, leaving only the iris atrophy, pupil dilation, glaucoma. If there is no such sign in an acute episode, the iris and pupil are normal.
2) Adhesion occurs in the corner of the room. If the adhesion range reaches 1/2~2/3 square corner, the drainage of the aqueous water is blocked and the IOP is increased.
3) The early visual nipple is still normal. When the disease progresses to a certain stage, the papillary gradual appearance of glaucoma pathological depression and atrophy.
4) Visual field: early normal, late glaucoma visual field defect, visual field defect gradually progress, and finally completely blind and enter the absolute period.
Absolute stage
Total vision loss.
(1) Symptoms: Because the patient has long tolerated high intraocular pressure, the symptoms are not obvious, only mild eye pain, but some cases have obvious symptoms.
(2) Signs: mild contusion of the bulbar conjunctiva, dilatation of the anterior ciliary ganglion, mild edema of the corneal epithelium, recurrent large vesicles or epithelial exfoliation, shallow anterior chamber, opacity of the lens, high IOP. In the late stage, the IOP can be lower than normal due to degeneration of the entire eyeball, and finally the eyeball shrinks. Because of the low resistance of this eyeball, corneal ulcers often occur and even develop into endophthalmitis.
Examine
Examination of acute angle-closure glaucoma
1. The visual acuity drops sharply.
2, the eye pressure suddenly rises, the eyeball is as hard as a stone.
3, mixed hyperemia is obvious.
4, the cornea is fog-like edema, the pupil is oval and large, and has a green appearance.
5, the anterior chamber is shallow, the anterior chamber angle is blocked.
Diagnosis
Diagnosis and diagnosis of acute angle-closure glaucoma
diagnosis
According to eye swelling, eye pain, rainbow vision, vision loss, ipsilateral migraine and typical symptoms of eyelid and nasal root pain, accompanied by anterior segment changes, such as conjunctival hyperemia, corneal epithelial edema, shallow anterior chamber and semi-open pupil Diagnosis, such as elevated IOP, closed angles, etc., can be made.
A small episode of the prodromal period, short duration, not easy to be seen by doctors, can be diagnosed according to the typical medical history, characteristic shallow anterior chamber, narrow angle. Excitation test can also be used to assist diagnosis, such as darkroom test or darkroom plus prone test, that is, the patient sits or prone in the dark room for 1~2 hours, then measures the IOP in dark light and checks the angle of the room. The IOP rises 8mmHg, the angle of the room Closed to be positive. If the pupil is dilated in the dark room, keep it awake to avoid shrinking the pupil due to sleep. Prone to advance the position of the lens can increase the pupil block. The symptoms and signs of acute attacks are typical and it is not difficult to make a diagnosis.
Differential diagnosis
(1) Differential diagnosis of acute angle-closure glaucoma and acute iridocyclitis and acute conjunctivitis:
Acute angle-closure glaucoma | Acute iridocyclitis | Acute conjunctivitis | |
vision | Extremely declining | Different degrees of decline | normal |
symptom | Acute eye pain, headache, nausea and vomiting | Photophobia, tears, deep pain in the eyeballs and eyelids, tenderness in the ciliary body | Foreign body sensation, burning sensation, purulent secretion |
Congestion | Blood in front of the eye | Mixed congestion | Conjunctival hyperemia |
cornea | Cloudy turbidity | Mild or edema | Transparent |
KP | Dust-like pigmentation | Pigmented KP size varies | no |
Front room | Lightening, the water is shining | Obvious water splash | normal |
pupil | Vertical elliptical enlargement, slow response to light, no post-adhesion | Shrink, slow response to light, no adhesion after iris | normal |
Crystal | Some have glaucoma | Anterior capsule has exudation | normal |
Corner | Occlusion | Open or occluded | normal |
intraocular pressure | Significantly elevated | Most normal or high | normal |
(2) Identification with other systemic diseases of the whole body: Because of acute symptoms of closed-angle glaucoma, headache, nausea, vomiting and other symptoms may be misdiagnosed as cerebrovascular disease or gastrointestinal system disease, neglecting eye examination and delay. The treatment of glaucoma causes serious consequences and even blindness. The medical history should be asked in detail, and it may be glaucoma. It is not difficult to make a correct diagnosis as long as necessary eye examinations are performed.
