Primer Açı Kapanması Glokomunda Güncel Tanı ve Tedavi

Açı kapanması glokomu dünyada önemli körlük nedenlerinden birisi olup, periferik irisin ön kamara açısını apozisyonel veya sineşiyel olarak kapaması sonucu göz içi basıncı artışı, buna bağlı olarak da optik sinir başı hasarı ve görme alanı kaybı ile karakterizedir. Glokoma bağlı körlük nedenlerinin yaklaşık yarısını oluşturmaktadır. İleri yaşta, kadınlarda ve hipermetroplarda daha sık görülür. En sık pupiller blok mekanizmasına bağlı gelişmekle birlikte göze ait bir takım anatomik risk faktörleri de bulunmaktadır. Oftalmolojide yeni görüntüleme tekniklerinin gelişmesi ile primer açı kapanması glokomunun patogenezi ve tedavisinde yeni yaklaşımlar ortaya çıkmıştır. Tanı esas olarak gonyoskopi ile konulmakla birlikte ön segment optik koherens tomografisi ve ultrason biyomikroskopisi de tanıyı destekleyen diğer görüntüleme teknikleridir. Tedavi kararında periyodik açı muayenesi önem taşımaktadır. Tıbbi tedavide aköz dışa akımını artıran ve anatomik olarak açının periferik iris ile kapanmasını önleyen ajanlar öncelikli olarak tercih edilir. Pupiller blok mekanizması ile gelişen açı kapanmasında laser iridotomi, plato iris gibi pupiller blok dışı mekanizmalarda ise laser periferal iridoplasti yapılır. Son zamanlarda, lensin açı kapanması gelişimindeki rolünün anlaşılması nedeniyle lens ekstraksiyonu ile birlikte goniosineşioliz ameliyatları tıbbi tedavi ve laser iridotominin başarısız olduğu olgularda 2. Seçenek olarak tercih edilmeye başlamıştır. Primer açı kapanması glokomunda filtran cerrahinin komplikasyonları fazla olup lens ekstraksiyonuna rağmen göz içi basıncı kontrol altına alınamayan olgularda uygulanmaktadır.

Anahtar Kelimeler:

açı kapanması, glokom, laser iridotomi

Current Diagnosis and Management of Primary Angle Closure Glaucoma

Angle closure glaucoma is one of the leading cause of the glaucoma in the worldwide. It is characterized by appositional or synechial closure of the anterior chamber angle by peripheral iris resulting with intraocular pressure elevation, optic nerve head damage and visual field loss. It accounts for about fifty percent of blindness caused by glaucoma. It is more prevalent in female, hyperopic and elderly patients. Although the most common mechanism responsible for the primary angle closure glaucoma is pupillary block, there are additional some anatomic risk factors. New insights have been developed in the pathogenesis and the treatment approach of the angle closure glaucoma with the development of the new imaging technologies in ophthalmology. Diagnosis based on gonioscopy and aided with ultrasound biomicroscopic and anterior segment optical coherence tomography. Serial gonioscopy is important in the treatment decision. Drops that increase aqueous outflow and prevent angle closure with peripheral iris are the first line preferred medication in the medical treatment. Laser iridotomy should be performed if the angle closure caused by pupillary block mechanism. Argon laser peripheral iridoplasty is effective for the mechanism of closure other than pupillary block such as plateau iris syndrome. Phacoemulsification with or without goniosynechialysis is an alternative treatment if the medical and laser treatment are ineffective. Filtering surgery has serious post-operative complications in patients with primary angle closure glaucoma. For this reason, it performed in cases if the intraocular pressure cannot be controlled despite lens extraction.

Keywords:

angle closure, glaucoma, laser iridotomy,

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1. American Academy of Ophthalmology Glaucoma Panel (2015): Preferred Practice Pattern Guidelines. Primary Angle Closure. American Academy of Ophthalmology (www.aao.org/aboutpreferred-practice-patterns).
2. Sun X, et al., Primary angle closure glaucoma: What we know and what we don’t know, Progress in Retinal and Eye Research (2016) http://dx.doi.org/10.1016/j.preteyeres.2016.12.003
3. Wright C, Tawfik MA, Waisbourd M, Katz LJ. Primary angle-closure glaucoma: an update. Acta Ophthalmol. 2016: 94 (3): 217–225
4. Amerasinghe N, Zhang J, Thalamuthu A, et al. The heritability and sibling risk of angle closure in Asians. Ophthalmology 2011; 118(3): 480-485.
5. Vithana EN, Khor C, Qiao C, et al. Genome-wide association analyses identify three new susceptibility loci for primary angle closure glaucoma. Nat Genet 2012; 44(10): 1142-1146
6. Shabana N, Aquino MC, See J, Ce Z, et al. Quantitative evaluation of anterior chamber parameters using anterior segment optical coherence tomography in primary angle closure mechanisms. Clin Exp Ophthalmol 2012:40 (8);792-801
7. Nongpiur ME, He M, Amerasinghe N, et al. Lens vault, thickness, and position in Chinese subjects with angle closure. Ophthalmology . 2011; 118 (3): 474-479.
8. Kumar RS, Tantisevi V, Wong MH, et al. Plateau iris in Asian subjects with primary angle closure glaucoma. Arch Ophthalmol 2009; 127 (10):1269-1272.
9. Ng WS, Ang GS, Azuara-Blanco A. Laser peripheral iridoplasty for angle-closure.Cochrane Database Syst Rev 2012:15;(2):CD006746. doi: 10.1002/14651858.CD006746.pub3.
10. Marchini G, Pagliarusco A, Toscano A, Tosi R, Brunelli C, Bonomi L. Ultrasound biomicroscopic and conventional ultrasonographic study of ocular dimensions in primary angle-closure glaucoma. Ophthalmology 1998: 105 (11);2091-2098
11. Sihota R, Lakshmaiah NC, Agarwal HC, Pandey RM, Titiyal JS. Ocular parameters in the subgroups of angle closure glaucoma. Clin Exp Ophthalmol 2000; 28(4): 253-258
12. Quigley HA, Friedman DS, Congdon NG. Possible mechanisms of primary angleclosure and malignant glaucoma. J Glaucoma 2003; 12(2): 167–180.
13. Arora KS, Jefferys JL, Maul EA, Quigley HA. The choroid is thicker in angle closure than in open angle and control eyes. Invest Ophthalmol Vis Sci 2012:53 (12);7813-7818
14. Yang H, Yu PK, Cringle SJ, Sun X, Yu DY. Quantitative study of the microvasculature and its endothelial cells in the porcine iris. Exp Eye Res 2015; 132, 249-258 doi:10.1016/j.exer.2015.02.006. Epub 2015 Feb 11.
15. Zhou M, Wang W, Huang W, et al. Is increased choroidal thickness association with primary angle closure? Acta Ophthalmol 2014: 92(7); 514-520.
16. Tan PE, Yu PK, Cringle SJ, Morgan WH, Yu DY. Regional heterogeneity of endothelial cells in the porcine vortex vein system. Microvasc Res 2013;89:70-79 doi: 10.1016/j.mvr.2013.06.004. Epub 2013 Jun 15.
17. Schacknow PN, Samples JR. The Glaucoma Book: A Practical, Evidence-Based Approach to Patient Care. New York 2010: Springer Science + Business Media LLC.
18. Schacknow PN, Samples JR. The Glaucoma Book: A Practical, Evidence-Based Approach to Patient Care. 2010: New York: Springer Science + Business Media LLC.
19. Lee JR, Choi JY, Kim YD, Choi J. Laser peripheral iridotomy with iridoplasty in primary angle closure suspect: anterior chamber analysis by pentacam. Korean J Ophthalmol 2011:25 (4); 252–256
20. Azuara-Blanco A, Burr J, Ramsay C et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet 2016:388 (10052);1389-1397.
21. Tham CC, Kwong YY, Baig N, Leung DY, Li FC & Lam DS. Phacoemulsification versus trabeculectomy in medically uncontrolled chronic angle-closure glaucoma without cataract. Ophthalmology 2013:120 (1);62–67.
22. Lam DS, Leung DY, Tham CC, Li FC, Kwong YY, Chiu TY, Fan DS. Randomized trial of early phacoemulsification versus peripheral iridotomy to prevent intraocular pressure rise after acute primary angle closure. Ophthalmology 2008;115 (7): 1134–1140.
23. Ng WT, Morgan W .Mechanisms and treatment of primary angle closure: a review.Clin Experiment Ophthalmol 2012:40 (4); e218–e228
24. Leggio GM, Bucolo C, Platania C., Salomone S, Drago F. Current drug treatments targeting dopamine D3 receptor. Pharmacol. Ther 2016:165:164-177. doi: 10.1016/j.pharmthera.2016.06.007. Epub 2016 Jun 22.