AIM STEP 10
Student Memory Support
Topic 9 — Angle-Closure, Secondary Glaucoma & Treatment
4th Year MBBS • EYE Module • High-yield memory reinforcement and last-minute revision
1. High-Yield Flashcards
Tap each question to reveal the answer.
What is the usual mechanism of primary angle closure?
Relative pupillary block causes iris bombé and obstruction of the trabecular meshwork.
How does the primary angle-closure spectrum progress?
PACS → PAC → PACG.
What finding makes primary angle closure become primary angle-closure glaucoma?
Glaucomatous optic-nerve damage with corresponding functional loss.
Which pupil appearance is typical in acute angle closure?
A mid-dilated, poorly reactive pupil.
Why do patients with acute angle closure see colored halos?
Markedly raised IOP causes corneal endothelial dysfunction and corneal edema.
Which examination directly assesses the anterior chamber angle?
Gonioscopy.
What is the definitive treatment for pupillary-block angle closure?
Laser peripheral iridotomy after initial pressure control.
What is the initiating pathological process in neovascular glaucoma?
Retinal ischemia stimulates VEGF-driven anterior-segment neovascularization.
What is rubeosis iridis?
Abnormal new vessels developing over the iris, especially around the pupillary margin.
Which treatment addresses the ischemic retinal drive in neovascular glaucoma?
Panretinal photocoagulation; anti-VEGF is an important adjunct for rapid vessel regression.
What causes phacomorphic glaucoma?
A swollen intumescent cataractous lens crowds the anterior segment and closes the angle.
What causes phacolytic glaucoma?
Leaked proteins from a hypermature cataract and macrophages obstruct the trabecular meshwork.
What is the key anterior-chamber difference between phacomorphic and phacolytic glaucoma?
Phacomorphic has a shallow chamber; phacolytic usually has a relatively deep chamber.
Which glaucoma drugs mainly reduce aqueous production?
Beta-blockers, alpha-2 agonists and carbonic anhydrase inhibitors.
What is the main action of prostaglandin analogues in glaucoma?
They lower IOP mainly by increasing uveoscleral aqueous outflow.
2. Mnemonics
Mnemonic Title: Acute Angle-Closure Pattern
PAIN
Meaning: Painful red eye • Acuity reduced • IOP markedly raised • Nausea/vomiting with corneal haze and mid-dilated pupil.
Mnemonic Title: Neovascular Glaucoma Sequence
R-V-F-C
Meaning: Retinal ischemia → VEGF → Fibrovascular membrane → Contractile synechial angle closure.
Mnemonic Title: Lens-Induced Glaucoma Difference
M = Massive, L = Leaking
Meaning: Phacomorphic = massive swollen lens causing angle crowding; phacolytic = leaking lens proteins blocking trabecular outflow.
3. Memory Tables
Phacomorphic vs Phacolytic Glaucoma
| Feature | Phacomorphic | Phacolytic |
|---|---|---|
| Lens | Intumescent, swollen cataract | Hypermature cataract |
| Mechanism | Mechanical angle crowding | Protein/macrophage trabecular blockage |
| Anterior chamber | Shallow | Relatively deep |
| Angle | Closed | Usually open |
| Definitive treatment | Cataract extraction | Cataract extraction |
Major Glaucoma Treatments and Their Main Roles
| Treatment | Main Role | Typical Indication |
|---|---|---|
| Peripheral iridotomy | Relieves pupillary block | Primary angle closure |
| Iridoplasty | Pulls peripheral iris from angle | Persistent appositional narrowing |
| Trabeculoplasty | Improves trabecular outflow | Accessible open angle |
| PRP | Reduces retinal ischemic drive | Neovascular glaucoma |
| Trabeculectomy / drainage device | Creates alternative drainage | Uncontrolled or refractory glaucoma |
4. Rapid Revision Points — Last-Minute Revision
Must Remember:
- Primary angle closure is mainly an aqueous outflow problem caused by peripheral iris obstruction of the trabecular meshwork.
- PACS has anatomical risk without glaucomatous optic neuropathy; PACG includes optic-nerve damage.
- Acute angle closure causes pain, red eye, visual reduction, corneal edema, shallow chamber and a mid-dilated poorly reactive pupil.
- Gonioscopy identifies the angle mechanism; tonometry measures the pressure rise.
- Acute pupillary block requires immediate IOP lowering followed by definitive peripheral iridotomy.
- Rubeosis iridis in a high-pressure eye should trigger consideration of retinal ischemia and neovascular glaucoma.
- Neovascular glaucoma requires treatment of both IOP and the underlying retinal ischemic drive.
- Phacomorphic glaucoma is mechanically closed-angle; phacolytic glaucoma is protein-mediated trabecular obstruction.
- Beta-blockers require caution in asthma, bradycardia and heart block.
- Cyclodestructive procedures are mainly reserved for selected refractory glaucomas, especially when visual potential is poor.
KMU Exam Trap: Acute angle closure describes the emergency presentation; primary angle-closure glaucoma specifically requires established glaucomatous optic-nerve damage.
5. Clinical Memory Hooks
Sudden painful red eye + halos + vomiting + mid-dilated pupil → acute angle-closure emergency.
Diabetic or retinal vascular disease + iris new vessels + high IOP → neovascular glaucoma from retinal ischemia.
Swollen cataract + shallow chamber + painful high-pressure eye → phacomorphic glaucoma.
Hypermature cataract + relatively deep chamber + inflammatory material + raised IOP → phacolytic glaucoma.
6. Starred High-Yield Exam Points
- ⭐ Pupillary block → iris bombé → trabecular obstruction → rapid IOP rise is the core mechanism of primary acute angle closure.
- ⭐ Laser peripheral iridotomy is the definitive treatment for the pupillary-block component after initial stabilization.
- ⭐ Gonioscopy is the key examination for defining anterior chamber angle closure.
- ⭐ Neovascular glaucoma: retinal ischemia → VEGF → rubeosis/fibrovascular membrane → secondary angle closure.
- ⭐ Phacomorphic = shallow closed angle from a swollen lens; phacolytic = relatively deep open angle with protein-mediated trabecular obstruction.
- ⭐ Prostaglandin analogues increase uveoscleral outflow, whereas beta-blockers and carbonic anhydrase inhibitors mainly reduce aqueous production.