RAJIV GANDHI UNIVERSITY OF

HEALTH SCIENCES
IN KARNATAKA, BANGALORE
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS
FOR DISSERTATION
1. Name of the candidate
and address

DR. SHRUTHI. S.SHENAVA

P.G. QUARTERS
YENEPOYA MEDICAL COLLEGE
HOSPITAL
DERALAKATTE
MANGALORE-575 018

2. Name of the Institution

YENEPOYA MEDICAL COLLEGE,

DERALAKATTE
MANGALORE-575 018

3. Course of Study and the

M.S.Degree in Ophthalmology

Subject
4. Date of admission to course 24th April, 2007
5. Title of the Topic

Study of glaucoma in eyes with shallow

anterior chamber

6. Brief Resume of the intended work:

6.1 Need for the study:
Glaucoma is a leading cause of irreversible blindness through out the world.
Angle closure glaucoma is a major cause of visual morbidity in East Asia.
The overall prevalence of primary angle-closures glaucoma (PACG)) in a rural
population of southern India was 1.58%. There was a female preponderance, and
the disease tends to be asymptomatic 1.
Eyes with primary angle closure tend to share certain biometric characteristics.
These include shallow anterior chamber depth (ACD), thick lens, anterior lens
position, small corneal diameter with small radius of curvature and a short axial
length 2,3. Among these, the shallow anterior chamber depth is regarded as the
cardinal risk factor in most ethnic groups. Photogrammetric studies of all forms of
angle closure glaucoma have revealed anterior chamber depths, volumes and
diameters that are smaller than matched controls 4. So one of the aims of this study
is to know the prevalence of angle closure glaucoma I n those patients who have a
shallow anterior chamber depth amongst those who attend the ophthalmology OPD
in Yenepoya Medical College.
Peripheral anterior synechiae compromise the drainage of the aqueous humor and
results in a rise of IOP, and thus contributes to the optic neuropathy. Hence it is
important to assess in detail those anterior chambers which on screening are found
to be suspiciously shallow, in order to detect the presence of peripheral anterior
synechiae. In this study, the association between the gonioscopic angle width and
peripheral anterior synechiae in the population with shallow anterior chamber will
also be studied.
It is well known that chronic angle closure and creeping angle closure are
relatively asymptomatic and may mimic Primary open angle glaucoma (POAG) in
their presentation. In chronic angle closure glaucoma the angle closure may be
either due to appositional or synechial mechanism. The more extensive the PAS, the
more chronic is the disease process in the patient of angle closure glaucoma.
Therefore the chronicity i.e. the extent of PAS is expected to correlate with the
severity of visual field defects. In this study I am going to analyze the field changes
in the patients with shallow anterior chamber and peripheral anterior synechiae or
appositional closure to determine the severity of visual loss and correlate it with
extent of the synechiae.

6.2 Review of Literature:

Glaucoma is a condition of multi- factorial optic neuropathy in which there is
characteristic acquired loss of optic nerve fibres. The definitive characteristics are
based on either visual field loss or appearance of the disc or retinal nerve fiber layer
defect associated either with a raised or normal IOP 5. Glaucoma is classified
on the basis of initiating events into
(A) Open angle glaucoma
(B) Angle closure glaucoma
(C) Developmental glaucoma,
(D) Glaucoma associated with systemic and other ocular disorders
It is estimated that by the year 2020, 79.6 million people would be burdened
by glaucoma. 47% of the glaucoma world wide would be in Asians with more than
75% being angle closure 6. At present twelve million Indians are affected by
glaucoma accounting for 12.8% of the blindness in the country7.
Hospital based data from India report primary open angle glaucoma
(POAG) to be as common as primary angle closure glaucoma (PACG) with 45% to

55% of primary glaucoma being PACG 8. In the glaucoma clinic of an eye hospital,
45.9% of all primary adult glaucoma was of the angle closure type
Of these 24.8% had acute angle closure glaucoma, 31.2% had sub acute and 44%
had chronic glaucoma9.
Angle closure glaucoma may be either
(a) Pupillary block glaucoma,
(b) Plateau iris syndrome,
Pupillary block glaucoma may further be sub divided into
1) Acute angle closure,
(2) Sub acute angle closure,
(3) Chronic angle closure,
(4) Creeping angle closure
A subset of chronic angle has been called creeping angle- closure glaucoma in
which peripheral anterior synechiae slowly advances forwards circumferentially;
giving the appearance that iris is becoming more and more anterior 10.
Chronic angle closure glaucoma (CACG) refers to an eye in which portions
of the anterior chamber angle are closed permanently by peripheral anterior
synechiae (PAS).
Some of the predisposing factors for chronic angle closure glaucoma are
1. Hypermetropic eyes with shallow anterior chamber, a relatively anteriorly
positioned lens and a short axial length 11.
2. East or south East Asian ethnic background is another important risk factor for
the development of chronic angle- closure glaucoma.
3. Age, female gender and a familial tendency.
The characteristic shallow anterior chamber of angle closure glaucoma is
caused by abnormal correlation between structures of lens and eyeball 12. The
crystalline lens continues to grow through out life, partly at the expense of the
anterior chamber, the depth and volume of which gradually diminish. The growth
of the lens leads to the shallowing of approximately 0.35 to 0.50 nm of the ACD in 50
years 12.The diminution of dimensions of the anterior chamber caused by the growth
of the lens may play an important role in the pathogenesis of angle- closure
glaucoma.

Mechanism of Angle closure:

There are two mechanisms which can lead to primary angle closure
glaucoma and these are: a) pupillary block mechanisms and b) plateau iris
mechanism.
In primary pupillary block glaucoma, eyes that have a narrow anterior
chamber angle and other predisposing factors in the form of hypermetropia,
thickened lens with old age, etc develop a pupillary block. Certain precipitating
events are responsible for this condition when the pupil becomes middilated, and
there is a block to the passage of the aqueous humor from the posterior chamber to
the anterior chamber. A pressure gradient builds up in the posterior chamber
wherein the peripheral part of the iris is pushed against the peripheral cornea and
the trabecular meshwork is obstructed by this peripheral part of the iris. This leads
to a sudden and acute rise in IOP causing acute angle closure glaucoma with
symptoms like severe headache and vomiting with blurred vision.
If the anterior chamber angle is not blocked for 360 degrees then the rise in
IOP is less severe and sudden and does not last very long. Accordingly the
symptoms are less severe. This condition is known as intermittent angle closure and
associated with some amount of trabecular damage with each attack, which may

account for the constant rise in IOP even with an open angle in parts.
Plateau iris refers to an anatomical configuration in which iris root angulates
forward and then centrally. The iris root is often short and inserted anteriorly on
the ciliary face, so that the angle is shallow and narrow. The iris surface is relatively
flat and the anterior chamber is not unusually shallow. In plateau iris syndrome this
pre-existing anterior insertion of the iris blocks the trabecular meshwork, more so
with the dilatation of the pupil resulting in a sudden and rapid rise in the IOP.
In chronic angle closure the iris slowly comes to rest against the trabecular
meshwork and to cover it, initially covering only small portions, leading to slow and
gradual elevation of IOP. This process is often painless and asymptomatic.
Appositional versus synechial angle closure:
In appositional angle closure, the iris rests against the trabecular meshwork,
and covers it, preventing aqueous outflow in the absence of synechiae formation and
causing a rise in IOP. In these conditions, the iris may spontaneously fall away from
the trabecular meshwork, with or without treatment permitting normal aqueous
escape once again and lowering the IOP. Appositional angle closure was frequently
observed in eyes with shallow peripheral anterior chamber under dark conditions in
Japanese. The angle width evaluated with conventional gonioscopic grading related
well to the presence of appositional angle closure.
Synechial angle closure exists when the iris has become permanently
adherent to the trabecular meshwork, chronically obstructing aqueous outflow.
This permanent adherence is caused by fibrosis that develops between the anterior
surface of the iris and the surface of the trabecular meshwork.
In eyes with dark iridis, another mechanism of progressive angle- closure is
more common. The closure is circumferential and begins in the deepest portion of
the angle. Closure occurs more evenly in all quadrants, so that the angle
progressively becomes shallower. The appearance over a period of time is of a
progressively more anterior iris insertion. Lowe has termed this, creeping angleclosure. The PAS gradually creeps up the ciliary face to the scleral spur and then to
the trabecular meshwork.

Presentation:
The patient may be symptomatic or asymptomatic. The eye may be congested
and irritable as in acute angle closure, or quiet as in chronic and creeping angle
closure where the patient is asymptomatic. The visual acuity is decreased. The optic
disc may show glaucomatous cupping. Gonioscopy reveals anterior chamber angle
closed by PAS. The visual field defects are similar to those seen in Primary open
angle glaucoma.
Acute and chronic angle closure glaucoma patients are most likely to have a
greater extent of PAS than patients in the angle- closure hypertension or ACG
suspect subtypes 13. PAS may be narrower in earlier stages and broader in the later
stages. PAS was found most frequently in the superior angle of the eye which is
narrower than the inferior angle. The extent of synechial closure of the angle may
play a role in raising the IOP levels in later stages of the disease rather than in the
early stages (13). It has been found that there is a clear association between narrow
angles and peripheral anterior synechiae (PAS) 14.
Several studies have demonstrated a possible relationship between the extent of
angle closure by PAS and the failure of iridotomy to control IOP or to prevent
progression of glaucoma 15.Once glaucomatous optic neuropathy associated with
synechial angle closure occurs, iridotomy alone is relatively ineffective in controlling
IOP 16. The extent of PAS may be regarded as a reliable indicator of the severity of
glaucomatous optic nerve damage in PACG and especially in chronic PACG 17.

6.3: Objectives of the study:

1. To determine the prevalence of angle closure in eyes with shallow
anterior chamber.
2. To compare the visual morbidity due to the various types of angles
closure in eyes with shallow anterior chamber.

7.0: Materials and methods:

7.1 Source of Data:
Patients attending the outpatient department of Ophthalmology, Yenepoya
Medical College Hospital, Deralakatte, will be screened initially by torch light
examination for the presence of a shallow anterior chamber. It is proposed to study
200 eyes with shallow anterior chamber

7.2: Methods of collection of data:

Eyes with shallow anterior chamber as detected by torch light examination
will be assessed by the van Herrick method for the depth of the peripheral anterior
chamber and they will be graded from 1 to 4.
These angles will be further evaluated by gonioscopic examination to study the
following:
1.
The width of the angle of the anterior chamber
2.
The configuration of the peripheral iris
3.
The insertion of the iris root into the ciliary body.
4.
The presence of PAS, its insertion and its extent.
5.
Appositional closure Vs synechiae closure.
Based on the history and the gonioscopy findings, the eyes will be labeled as open angles,
acute angle closure, subacute angle closure, chronic angle closure, creeping angle closure and
plateau iris. The eyes will then be further evaluated by fundus examination, applanation
tonometry and a threshold Perimetry to determine the extent of visual loss.
All the above data will be recorded as per proforma given below.

Proforma
Case No:
Name:
Age:
Address:

Hospital No:
Date:
Sex:
Occupation:

I undersigned give consent for ocular examination which is noninvasive.

Name of the patient \ by stander
Sl. No.

Complaints

1
2
3
4
5
6
7

Blurring of vision
Frequent change of glasses
Pain/pressure
Redness of eyes
Constitutional symptoms
Coloured haloes around light
Impaired dark adaptation

signature
RE

Duration

LE

Duration

8
9
10
11
12
13

Awareness of scotoma
Trauma to eyes
Past ocular surgery
Corticosteroid use
Known case of glaucoma
Use of miotics

2. Past History:
H/o recurrent attacks
Diabetes
Hypertension
Use of glasses & duration
3. Family history of glaucoma:
4. Habits:
Alcohol
Smoking
Excessive coffee/tea
5. Examination:
1.
General physical examination
Pulse
Respiratory rate:
BP
CVS:
CNS:
P/A
2.
Ocular examination
A. Gaze
B. Ocular movements
Dictions:
Versions:
Vergence:
C. Examination by oblique illumination and slit-lamp
RE
1
2
3
4
5
6
7

Lids
Adnexa
Conjunctiva
Sclera
Cornea
Anterior Chamber
(Van Herrick method)
Iris

LE

8
9

Pupil
Lens

B.

Vision:

RE

LE
Sine
Pin hole
Cum
Near vision

C.

Refraction:

D.
Ocular Tension with Goldman applanation Tonometer (in mm
of hg) corrected for CCT
RE
LE

E.

FUNDUS EXAMINATION:
RE

Size
Disc
Shape
Colour
Size
C:D Ratio
Cup
Depth
Laminar dot sign
Central
Nasal Shift
retinal
Bayoneting
vessels
Venous Pulsation
Arterial pulsation
Neuro-retinal Thinning (ISNT)
Rim
Pallor
Notching
Hemorrhage over disc
Peripalillary atrophy
Macula
Retinal periphery

LE

F. Gonioscopy using Goldman 3 mirror gonio lens (Spaeth grading):

RE
LE
Geometric angle between
cornea and iris
Insertion of iris
Iris contour
G.

Visual fields Humphrey automated threshold Perimetry.

RE
LE

6. Impression
1. Angle closure Type
Extent
Glaucoma
2. Visual morbidity
Visual acuity
Field loss

RE

LE

Statistical analysis using the chi square test will done to know the significance
of our findings.

Inclusion criteria:
1.
2.

All patients of 20 years or above age

Patients of both sexes.

Exclusion criteria:
1.
2.
3.
4.

Patients with visual loss due to known ocular or systemic disease.

Patients with history of intra ocular surgery
Patients with history of ocular trauma
Patients on long term miotics.

7.3: Does the study require any investigations or interventions to be

conducted on patients? If so briefly describe.
This study requires non- invasive investigations in the form of
1.
Tonometry.
2.
Gonioscopy for evaluation of the anterior chamber angle.
3.
Slit- lamp examination for grading of the angle and to rule out
secondary glaucoma.
4.
Ophthalmoscopy for optic disc evaluation
5.
Visual field analysis for evidence of angle closure glaucoma by
automated Perimetry
The above investigations are routine and non invasive. They are not harmful

to the patient and are meant to identify the risk factors for angle closure glaucoma
and its effects on vision, and hence it is likely to be beneficial to the patient. The
study does not require any medical or surgical intervention.

7.4: Has the ethical clearance been obtained from your institution in
case of 7.3?
Yes

8. BIBLIOGRAPHY:
1. Lingam H , Baskaran M, Pradeep G, et al. Prevalence of angle closure glaucoma
in a rural south Indian population. Arch ophthamol 2006; 124:403-409.
2. Alsbrik PH. Primary angle- closure glaucoma; oculometry, epidermiology, and ,
George R, Arv genetic in a high risk population. Acta ophthalmol. 1976;
127(suppl):530-31.
3. Lowe RF. Aetiology of the anatomical basis for primary angle closure glaucoma;
biometric comparison between normal eyes and eyes with primary angle-closure
glaucoma. Br J Ophthalmol 1970; 54:161-169.
4. Pupillary-Block Glaucomas. In: Bruce Shields, M, editor. Textbook of glaucoma.
4th ed. Philadelphia: Lippincott Williams & Wilkins; 1999. p.180.
5. Paul Lee. Screening for glaucoma. In: Myron Yanoff, Jay Duker S, editors.
Ophthalmology. . 2nd ed. St Louis: Mosby CV: 2004; P.12:2.1.
6. Quigly HA, Broma AT. The Number of people with glaucoma worldwide in 2010
and 2020. Br.J Ophthalmol 2006;90:262 7
7. Thomas R, Paul P, Maliyal J. Glaucoma in India .J glaucoma 2003;12:81-7.
8. Ramakrishana R, Nirmalan PK, Krishnadas R, Thulasiraj RD, Tielsch JM, Katz
J,et al. Glaucoma in a rural population in southern India. Ophthalmology 2003;
110:1484-90.
9. Sihota R, Agarwal HC. Profile of the subtypes of angle closure glaucoma in
tertiary hospital in North India. Indian J ophthalmol 1998;46:25-9
10. Becker-Shaffer. Primary Angle Closure glaucoma with papillary block. In:
Dunbar Hoskins, Michael A K. Editors. Becker-Shaffers Diagnosis and therapy of
the Glaucoma. 6th ed. New Delhi: Jaypee Brothers; 1989. p. 208.
11. Salmon JF. Predisposing factors for chronic angle closure glaucoma. Prog
Retin Eye Res .1999 Jan; 18(1):121-32.
12.
Lowe R F. Aetiology of the anatomical basis for primary angle-closure
glaucoma. Biometrical comparisions between normal eye and eyes with primary
angle-closure glaucoma. Br J ophthalmol 1970; 54:161-169.
13. Lee JY, Kim YY, Jung HR. Distribution and characteristics of peripheral
anterior synechial in primary angle closure glaucoma. Korean J Opthalmol 2006
Jan;20(2):104 -8. .
14. Foster PJ, Nolan WP, Aung T, et al. Defining occludable angles in population
surveys; drainage angle width, peripheral anterior synechial and glaucomatous
optic neuropathy in east asian people Br J Ophthalmol 2004; 88:484-490.
15. Salmon JF. Long term intraocular pressure control after Nd-YAG laser
iridotomy in chronic angle- closure glaucoma. Glaucoma 1993; 2:291-296.
16. Nalon WP, Foster PJ, Devereux JG, Uranchimeg D, Johnson GJ, Baasanhu J.
YAG Laser iridotomy treatment for primary angle closure in East Asian eyes.Br J
ophthalmol 2000;84:1255-1259.
17. Jun Sung Chol MD, Yong Yean Kim MD. Relationship between the extent of
peripheral anterior synechial and the severity of visual field defects in primary
angle closure glaucoma. Korean J Ophthalmol 2004; 8:100 -105.

10

9.Signature of candidate
10.Remarks of the guide

A clinical study to determine

the prevalence and severity of
angle closure glaucoma in a
population at risk
DR. CYNTHIA
ARUNACHALAM

11.0 Name of the Guide

(in block letters)

11.1 Designation of the

Guide
11.2

signature

11.3

Co-guide(if any)

11.4

signature

ASSOCIATE PROFESSOR

11.5 Head of the

department
11.6

signature

12.0

Principal

DR. NEELAM PUTHRAN

DR. R.N. SUJEER

12.1 Remarks of the

principal

12.2

Signature

11