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174

Case Report

Angle Closure Glaucoma with Myopia

Shaukat Ali Chhipa

Pak J Ophthalmol 2009, Vol. 25 No. 3
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See end of article for
authors affiliations

… ………………………

Correspondence to:
Shaukat Ali Chhipa
University Road Medical Services
ABC Plaza,Opp:Baitul-Mukkaram
Masjid, Main University Road
Karachi

Received for publication
September’ 2008
… ………………………

Reporting a case of 30 years old man who presented with pain and blurring
in his right eye in an offsite ophthalmic consulting clinic of The Aga Khan
university hospital. On the basis of history and clinical examination he was
diagnosed as a case of primary angle closure glaucoma (PACG), although
his refractive status was myopic. Narrowing of anterior chamber angle and
PACG are almost always associated with hyeropia. To my knowledge this
rare combination of PACG and myopia has never been reported before in
Pakistan. The patient was managed as for a PACG.

arrowing of the anterior chamber angle and
angle closure glaucoma are typically
associated with hyperopia. In PACG

elevation of intraocular pressure (IOP) occurs as a
result of obstruction of aqueous outflow by partial or
complete closure of the angle by the peripheral iris. A
normal optic nerve head and visual field do not
preclude a diagnosis of PACG. Hyeropic eyes which
are also frequently short have small corneal diameter
and relatively short axial length are at increase risk of
PACG1,2. Myopia rarely is observed in patients with
these conditions. No case series of such eyes has been
reported in the literature.

CASE REPORT
I am reporting a case of myopic patient having
primary angle closure glaucoma. 30 years man
presented with blurring and pain in his right eye for 2
days, which was initially severe as well as causing
haloes around light. The severity was decreased with
some oral medication in addition to topical timolol
advised by general practitioner. Patient had a history
of medical management for elevated intraocular
pressure in both eyes, which was clogged by him a
couple of moths ago. There was no significant medical
history and family history was also not contributory.

Vision in right eye was 20/200 with -3.50 D sph / -2.0
D cyl at 175 degrees, not improving further and 20/20
in left eye with -4.0D sph/ -1.25 D cyl at 175 degrees.
Slit lamp examination revealed circumciliary
congestion, hazy cornea, mid-dilated pupil, and
shallowing of anterior chamber with convex
appearance of iris in the periphery of right eye. In the
left eye there were no such signs except shallowing of
anterior chamber with convex appearance of iris in the
periphery. IOP was 43 mmHg and 16 mmHg in right
and left eyes respectively. After the initial examination
patient was advised to lie down supine and treated as
an acute congestive glaucoma by giving
Acetazolamide 500mg orally stat, Pilocarpine 2% eye
drops in both eyes and Timolo 0.5% eye drops in right
eye. Reassessment after an hour revealed relative
decrease in corneal haziness, decrease in dilation of
pupil and very sluggish reaction of pupil was evident.
The IOP had dropped to 20 mmHg. Gonioscopy
findings were momentous, as the angle was grade 0 in
three quadrants and grade 0-I in inferior quadrant of
the right eye, while gonioscopy of the left eye exposed
grade 0 in superior and temporal quadrants, grade I
and II in nasal and inferior quadrant respectively.
YAG laser iridotomy was advised in both eyes as an
initial step and until then Pilocarpine eye drops
should be continued in both eyes.

175

DISCUSSION
When attempting to explain angle closure one should
have in mind a system that facilitates the inclusion and
understanding of the various mechanisms involved in
iridocorneal apposition. The typical eye with primary
angle closure glaucoma has a hyperopic refractive
error, shorter than average axial length, larger than
average lens thickness, and a smaller than average
anterior chamber depth and volume3,4. The
identification of correct pathophysiology directs the
treatment to the appropriate underlying source of
angle closure. The most common cause of angle
closure is pupillary block5. In aging; increased lens
thickness, forward movement of the anterior lens
surface, and decrease in anterior chamber depth and
volume causes relatively pupillary block, which makes
it a disease of middle aged and older indivisuals1.
Review of literature has discovered almost no mention
of such patients. Lowe2 reported on 127 eyes of
patients diagnosed with primary angle closure
glaucoma, only 2 had myopia of more than -2.0 D.
Marchini6 reported a series of refraction in patients
with angle closure glaucoma, none of the 54 patients
had myopia. Hagan and Lederer7,8 reported a myopic
patient who was initially reported to have PACG, but
subsequently was observed to have lens subluxation.
Myopia and angle closure developed in two adults
who had retinopathy of prematurity were reported by
Michael9. Barkana5 have described 20 patients with a
spectrum of ophthalmic conditions leading to myopia
and angle closure. The primary relative pupillary
block which is the cause for angle closure in the large
majority of patients in the general population was
identified in his 9 described patients.
Because angle closure in myopic patients is unusual
and for the reason that gonioscopy in these patients
may not be performed routinely the clinician must
maintain a high index of suspicion. The case report of
this patient illustrates that myopic refraction does not

exclude the presence of angle closure and that this
should be sought by careful gonioscopy. I advocate
performing careful gonioscopy on all patients
undergoing initial examination.

Author’s affiliation
Dr. Shaukat Ali Chhipa
University Road Medical Services
ABC Plaza, Opp: Bait-ul-Mukkaram Masjid
Main University Road
Karachi.

REFERENCE
1. Bonomi L, Marchini G, Marraffa M, et al. Epidemiology of

angle-closure glaucoma: prevalence, clinical types, and
association with peripheral anterior chamber depth in the
Egna-Neumarkt Glaucoma study. Ophthalmology. 2000; 107:
998-1003.

2. Lowe RF. Aetiology of the anatomical basis for primary angle-
closure glaucoma. Biometrical comparisons between normal
eyes and eyes with primary angle-closure glaucoma. Br J
Ophthalmol. 1970; 54: 161-9.

3. Friedman DS, Gazzard G, Foster P. Ultrasonographic
biomicroscopy, Scheimpflug photography, and novel
provocative tests in contralateral eyes of Chinese patients
initially seen with acute angle closure. Arch Ophthalmol. 2003;
121: 633-42.

4. Tomlinson A, Leighton DA. Ocular dimensions in the heredity
of angle-closure glaucoma. Br J Ophthalmol. 1973; 57: 475-86.

5. Barkana Y, Shihadeh W, Oliveria C, et al. Angle closure in
highly myopic eyes. Ophthalmology. 2006; 113: 247-54.

6. Marchini G, Pagliarusco A, Toscano A. et al. Ultrasound
biomicroscopic and conventional ultrasonographic study of
ocular dimensions in primary angle-closure glaucoma.
Ophthalmology. 1998; 105: 2091-8.

7. Hagan JC III, Ledere CM Jr. Primary angle closure glaucoma
in a myopic kinkship. Arch Ophthalmol. 1985; 103: 363-5.

8. Hagan JC III, Ledere CM Jr. Genetic spontaneous late
subluxation of the lens previously reported as a myopic
kinkship with primary angle closure glaucoma. Arch
Ophthalmol. 1992; 110: 1199-1200.

9. Michael AJ, Pesin SR, Kartz LJ, et al. Management of late-
onset angle-closure glaucoma associated with retinopathy of
prematurity. Ophthalmology. 1991; 98: 1093-8.