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A 53-year-old woman with a severe headache, bilateral eye pain, blurred vision, and photophobia
Digital Journal of Ophthalmology 2011
Volume 17, Number 3
August 28, 2011
DOI: 10.5693/djo.03.2011.05.002
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Pedro Barros, MD | Department of Ophthalmology, Hospital Pedro Hispano, Porto, Portugal
Liliana Paris, MD | Department of Ophthalmology, Hospital Pedro Hispano, Porto, Portugal
Joana Martins, MD | Department of Ophthalmology, Hospital Pedro Hispano, Porto, Portugal
Paula Tenedorio, MD | Department of Ophthalmology, Hospital Pedro Hispano, Porto, Portugal
Differential Diagnosis
Primary angle-closure glaucoma (PACG) with pupillary block is the most common form of PACG and occurs in eyes in which apposition of the iris pupil against the crystalline lens or intraocular lens impedes the passage of aqueous humor from the posterior chamber to the anterior chamber. When the pressure in the posterior chamber surpasses that in the anterior chamber, the peripheral iris is pushed forward (iris bombé), occluding the iridocorneal angle. The frequency of PACG increases with age and is 2-4 times more common in women. In our case, pupillary block was absent.

Secondary angle-closure glaucoma with pupillary block may be associated with the following etiologies:
• The presence of posterior synechiae following ocular inflammation (eg, uveitis), trauma, or posterior lens implantation
• Use of miotics, which relax the zonules, producing a forward shift of the lens-iris diaphragm
• Cataract surgery with anterior chamber lens implantation (when iridectomy is not patent)
• Surgical aphakia, where the block is due to the apposition of the anterior hyaloid face to the iris pupil
• Pars plana vitrectomy with intravitreal silicone oil or gas

In our case there were no posterior synechiae, and the history was negative for use of miotics and eye surgery.

Secondary angle-closure glaucoma without pupillary block can be due to anterior pulling mechanisms or posterior pushing mechanisms. Anterior pulling mechanisms include peripheral anterior synechiae, neovascular glaucoma, iridocorneal endothelial syndrome, aniridia, and epithelial downgrowth. Posterior pushing mechanisms include malignant glaucoma, suprachoroidal hemorrhage, cysts and tumor of the ciliary body or iris, swelling and anterior rotation of the ciliary body and choroidal effusion.

PACG without pupillary block is usually due to a plateau iris configuration. Ultrasound biomicroscopy demonstrates anterior rotation of the ciliary body and ciliary processes that push the peripheral iris close to the angle wall.
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