Clinical and Experimental Ophthalmology 2005; 33: 478–482
Original Article
Prevalence and mechanism of appositional angle closure in
acute primary angle closure after iridotomy
Barry YM Yeung FRCS, Philip WC Ng FRCS, Thomas YH Chiu MRCS, Chi Wai Tsang MRCS, Felix CH Li
MRCS, Chung Chai Chi FRCS, Jimmy SM Lai FRCS, Clement CY Tham FRCS and Dennis SC Lam FRCS
Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
ABSTRACT
Purpose: A prospective observational case series to assess
the prevalence of appositional angle closure in darkness
among iridotomized Chinese eyes after acute primary angle
closure (APAC) with the use of both clinical methods and
ultrasound biomicroscopy.
Methods: Sixteen Chinese patients who had history of
APAC and subsequent successful treatment with laser
peripheral iridotomy were examined. Fourteen additional
control subjects were studied. Gonioscopy and ultrasound
biomicroscopic examination were performed in the dark.
Gonioscopic appearance of the angle was assessed, and
quantitative measurements of the angle from the ultrasound
biomicroscopic images were taken.
Results: Of the APAC eyes 55.6% had appositionally closed
angle clinically and in 38.9% only Schwalbe’s line was visi-
ble on gonioscopy. Ultrasound biomicroscopy confirmed
structurally different anterior segments between eyes with
APAC and the control eyes. In particular, the trabecular-
ciliary-process distances were markedly different between
the two groups.
Conclusion: This study documented a high prevalence of
appositional closure in iridotomized eyes after APAC in
Chinese patients. The anteriorly positioned ciliary body, as
documented in these cases by ultrasound biomicroscopy, is
the likely mechanism of the angle crowding in this patient
population.
Key words: appositional closure, ciliary body, patent iri-
dotomy, prevalence.
 Correspondence: Dr Barry YM Yeung, Department of Ophthalmology and Visual Science, The Chinese University of Hong Kong, Hong Kong Eye Hospital,
147K Argyle Street, Kowloon, Hong Kong, China. Email: ymyeung@ha.org.hk
INTRODUCTION
Primary angle closure glaucoma (PACG) is common among
the Chinese population.1,2 Recent studies have shown that a
large proportion of patients, after acute primary angle clo-
sure (APAC), develop an increase in intraocular pressure on
long-term follow up despite the presence of a patent laser
peripheral iridotomy (LPI).3 In many of these cases, medical
therapy fails and filtration surgery is required. The uncon-
trolled intraocular pressure may be a result of trabecular
damage or peripheral anterior synechiae (PAS) formation.
The latter is likely to play an important role in the develop-
ment of chronic angle closure even with the presence of a
patent iridotomy. A patent peripheral iridotomy, which can
only eliminate the pupillary block mechanism of angle clo-
sure, may not be sufficient on its own to prevent the forma-
tion of PAS. It is now well known that there are various other
mechanisms of angle closure, namely, plateau iris, lens-
induced and mixed type.4 It has also been postulated that
in Chinese eyes mixed mechanisms are involved in post-
iridectomy glaucoma.5,6 It is therefore reasonable to postu-
late that, in addition to pupillary block, the above various
mechanisms can also lead to appositional angle closure,
which in turn may contribute to synechial angle closure and
the subsequent development of chronic angle closure. When
a significant proportion of the angle is closed and the
intraocular pressure is subsequently raised, filtration surgery
may be the only treatment for the control of intraocular
pressure.
In this study, we examined the prevalence of appositional
angle closure in darkness among a group of patients with
patent LPI after an attack of APAC. Theoretically, an eye
with a patent LPI is assumed to be free of pupil block.
However, the occurrence of intraocular pressure (IOP) rise
in iridotomized eyes during the dark-prone test and dark
room provocative test have been observed by Hung.5,6
Mechanisms other than pupil block, including angle crowd-
Angle closure after iridotomy
ing, can be responsible for the IOP rise.5 In our study, the
rationale behind examining patients under dark environment
is in line with Hung’s observation. Any residual appositional
angle closure in these iridotomized eyes may possibly be
exaggerated and thus more readily detected along with
mydriasis in response to darkness. Apart from clinical exam-
inations, we also examined the eyes with ultrasound biomi-
croscope (UBM) in the dark to help us understand the
mechanisms of angle closure in Chinese patients.
METHODS
Sixteen consecutive Chinese patients who had APAC (acute
symptomatic attack with raised IOP and with the angle
closed on gonioscopy) and underwent laser iridotomy in
both eyes from October 2000 to February 2001 were pro-
spectively recruited at Hong Kong Eye Hospital to have
UBM examination of the eyes. Exclusion criteria were: (i)
cases of secondary angle closure, such as uveitis, iris neovas-
cularization, trauma or tumour; (ii) patients who were unable
to cooperate with the examination; (iii) eyes put on pilo-
carpine; and (iv) patients with history of previous intraocular
operation. Fourteen consecutive control patients (all
Chinese) of similar age and sex distribution were also pro-
spectively recruited from our general ophthalmic clinic
around the same period. Informed consents were obtained in
all studied subjects.
All subjects had detailed ophthalmic examination includ-
ing gonioscopy in the dark. Gonioscopy was performed with
the Posner indentation gonioscope. The room lights were
switched off and only a narrow beam of light from the slit
lamp was used. The patency of the LPI was assessed and
confirmed by retro-illuminatio and direct visualization of the
lens. The angle of each quadrant of each eye was examined
and the feature identified was recorded. The visible angle
structure that occupied more than 180∞ was taken to repre-
sent that eye.
Ultrasound biomicroscopy was performed with the com-
mercial model of the instrument (Paradigm Medical Indus-
tries, Salt Lake City, UT, USA) and with a 50 MHz
transducer. UBM examination was performed with the
patient lying supine. The room was kept in darkness and only
illuminated by the monitor of the UBM machine. The
patient was asked to fixate on a distant target with the fellow
eye to prevent accommodation. This had ensured that the
pupil size remained virtually constant and the angle config-
uration remained relatively unchanged. Under topical anaes-
thesia, a plastic eye-cup was used to separate the eyelids.
Methylcellulose 2.5% was used as the coupling agent. Radial
scans of 12, 3, 6, 9 o’clock positions and an axial scan were
performed. Quantitative measurements of various parame-
ters, namely, the anterior chamber depth (ACD), iris-zonule
distance (IZD), trabecular-ciliary process distance (TCPD)
and iris thickness (IT), were performed. The parameters were
measured according to the method published by Pavlin
et al.7–9 TCPD was used to assess the position of the ciliary
body and was measured on a line extending from the corneal
479
endothelium at a point 500 mm from the scleral spur perpen-
dicularly through the iris to the ciliary process. The IT was
measured along this line. The IZD corresponds to the pos-
terior chamber depth measured from the posterior iris surface
to the first visible zonular fibre at a point just clearing the
cliary process. All these quantitative measurements were per-
formed by a single well-trained operator (C.W.T.).
ANOVA test was used to verify that there was no signifi-
cant difference in the measurements taken from each quad-
rant within the same eye. A P-value of less than 0.05 was
considered significant. A characteristic image of the angle
from each eye was chosen for quantitative analysis. Plateau
iris was defined clinically as the configuration of the periph-
eral iris in which the root angulates sharply forward and then
centrally.10 For the fellow eyes in the APAC cases, the diag-
nosis of glaucoma was formulated when at least two of the
followings were detected: intraocular pressure ≥ 22 mmHg
on presentation, glaucomatous optic disc abnormality and
glaucomatous visual field defects (Humphrey 24-2 program).
Chronic angle closure was defined as an eye condition in
which acute attacks never occurred but PAS were detected.
RESULTS
There were 3 men and 13 women in the APAC group. There
were 3 men and 11 women in the control group. The mean
age of the patients in the APAC group was 69.8 ± 10.1 years.
The mean age of the control group was 71.1 ± 6.7 years. Two
patients had bilateral acute attack. Therefore, there were 18
eyes with APAC and 14 fellow eyes. Of the fellow eyes, 12
of them had no glaucoma and two had chronic angle closure
glaucoma.
Table 1 tabulates the gonioscopic appearance of the angle
in the APAC eyes and the fellow eyes.
Gonioscopically, eyes of all patients in the APAC group
had the appearance of the iris root angulating sharply for-
ward and then centrally. Figure 1 shows the characteristic
double hump or sine wave sign on indentation that occurred
in most of the eyes. On gonioscopy, synchial closure was
found in 10 APAC eyes and 6 fellow eyes. The extent of PAS
was about 90∞ in 14 eyes and 180∞ in the other two (both
were APAC eyes).
We demonstrated no statistically significant difference in
all the UBM parameters (TCPD, IT, IZD and ACD) between
Table 1. Gonioscopic appearance of the angle in the acute pri-
mary angle closure (APAC) eyes and in the fellow eyes
Appearance of the angle APAC eyes Fellow eyes
n (%) n (%)
Closed angle, Schwalbe’s line not 10 (55.6) 6 (42.9)
visible
Only Schwalbe’s line visible 7 (38.9) 7 (50)
Schwalbe’s line and non-pigmented 1 (5.6) 1 (7.1)
trabeculum visible
Total 18 (100) 14 (100)
480 Yeung et al.

the eyes with APAC and their fellow eyes (Table 2). When
comparing the eyes with APAC and the control group, all
but the IT were statistically different (Table 3). When com-
paring the fellow eyes and the control group, all but the IT
were statistically different (Table 4). Figures 2 and 3 show
the characteristic UBM image of the angle. Figures 4 and 5
show the UBM image of the angle of a control eye for
comparison. Concerning the type of angle closure in our
cases, one eye was type S (closure starting in the vicinity of
the Schwalbe’s line) and the rest were type B (closure starting
from the bottom of the angle recess).

DISCUSSION
Primary angle closure glaucoma is a heterogeneous entity. It
is often difficult to clinically classify the distinct types of
PACG with the use of indentation gonioscopy alone. UBM
is a very useful and important tool in identifying the different
characteristics in these angles. UBM also allows quantitative
measurements of distances between different structures.
These parameters have been proven to be very different in
the eyes with PACG and eyes in the normal population.9
In our series, there was no significant difference in any of
the parameters measured in the APAC eyes and in their
fellow eyes (Table 2). Thus, the fellow eyes are also at risk
of developing glaucoma, as documented in the literature.10,11
Figure 1. A gonioscopic picture showing double hump sign on An important difference between our normal control
indentation. cases and the APAC cases was the TCPD. This distance

Table 2. Comparison of quantitative measurements between the APAC eyes and the fellow eyes

Measurement APAC eyes Fellow eyes Two-tailed t-test significance

Mean SD Mean SD P-value
ACD (mm) 1660.50 179.56 1753.00 207.83 0.187
IT (mm) 345.00 72.49 346.43 91.95 0.961

ACD, anterior chamber depth; APAC, acute primary angle closure; IT, iris thickness.

Table 3. Comparison of quantitative measurements between the APAC eyes and the control group

Measurement APAC eyes Control group Two-tailed t-test significance

Mean SD Mean SD P-value
TCPD (mm) 539.61 98.70 721.44 172.00 <0.001
IZD (mm) 429.39 59.94 516.48 97.75 0.001
ACD (mm) 1660.50 179.56 2300.33 325.76 <0.001
IT (mm) 345.00 72.49 347.89 73.30 0.897

ACD, anterior chamber depth; APAC, acute primary angle closure; IT, iris thickness; IZD, iris-zonule distance; TCPD, trabecular-ciliary
process distance.

Table 4. Comparison of quantitative measurements between the fellow eyes and the control group

Measurement Fellow eyes Control group Two-tailed t-test significance

Mean SD Mean SD P-value
TCPD (mm) 479.14 88.00 721.44 172.00 <0.001
IZD (mm) 411.36 76.30 516.48 97.75 0.001
ACD (mm) 1753.00 207.83 2300.33 325.76 <0.001
IT (mm) 346.43 91.95 347.89 73.30 0.956

ACD, anterior chamber depth; IT, iris thickness; IZD, iris-zonule distance; TCPD, trabecular-ciliary process distance.
Angle closure after iridotomy
Figure 2. Ultrasound biomicroscope image of a typical angle
cross-section of our cases. The ciliary body is anteriorly positioned,
pushing the iris towards the trabeculum.
Figure 3. Diagrammatic representation of Figure 2, with ultra-
sound biomicroscope measurement positions displayed. IT, iris
thickness; IZD, iris-zonule distance; TCPD, trabecular-ciliary pro-
cess distance.
between the trabecular meshwork and the ciliary process was
significantly (P < 0.001) larger in our normal cases. As Pavlin
et al.9 pointed out that TCPD ‘defines the port through which
the iris must transverse and has implications as to the poten-
tial maximal angle opening’, we found it a very important
parameter in the UBM study of our cases. The short TCPD
can give rise to a short IZD, which was shown to be signif-
icantly shorter in our study group (P = 0.001). In addition, a
significantly shorter ACD found in our study group can make
the angle crowding worse in these eyes.
A striking finding of our study was that a very high pro-
portion of our patients (APAC eyes and the fellow eyes)
showed extensive appositional angle closure in the dark after
LPI. This observation may provide a clue to explain Hung
et al.’s finding in their provocation studies.5,6 Hung et al. found
that among the iridectomized eyes, the dark room tests
caused elevation of IOP of more than 8 mmHg in 2.7%, and
nearly 60% of the eyes showed positive results (i.e.
481
Figure 4. Ultrasound biomicroscope image of an angle cross-
section of a control eye. The ciliary body is more posteriorly
positioned than that in Figure 3.
Figure 5. Diagrammatic representation of Figure 4, with ultra-
sound biomicroscope measurement positions displayed. IT, iris
thickness; TCPD, trabecular-ciliary process distance.
≥8 mmHg rise) with prone-position tests in the dark.6 We
are aware that multiple unknown mechanisms may be
responsible for the IOP rise in the dark-prone and dark room
provocative tests as demonstrated by Hung et al.5,6 Although
our finding may not be able to offer direct or full explanation
to all the observations in Hung et al.’s studies (prone provoc-
ative test was not performed in our study), it has nevertheless
demonstrated an anatomical predisposition to IOP rise in
darkness in these iridotomized eyes, namely, the extensive
appositional closure observed in our studied patients. We
believe that this predisposition may contribute, at least to
some extent, to the IOP elevation in darkness, no matter
whether we are referring to dark room or dark-prone pro-
vocative test. In addition, Hung also demonstrated that pilo-
carpine was much more effective than timolol in preventing
IOP elevation in dark-prone provocative tests.5 The protec-
tive effect of pilocarpine is probably a result of the iris being
pulled away from the drainage angle (i.e. relieving the appo-
sitional closure as observed in our study).
482
In this study, we revealed a possible mechanism of appo-
sitional angle closure in APAC after LPI. In our series, the
ciliary body was so anteriorly positioned that it pushed the
iris towards the trabeculum and caused angle closure in most
of the cases. The features demonstrated in our patients
matched the plateau iris configuration described by Ritch12
and Pavlin et al.,7 in which the ciliary process, situating ante-
riorly, provides structural support beneath the peripheral iris
and prevents the iris root from falling away from the trabe-
cular meshwork after iridectomy. Moreover, in the UBM
examination, we found that the space between the iris root
and the trabecular meshwork was in wedge-shape (this two-
dimensional picture was not available from gonioscopy). In
fact, in most of our APAC patients we found that the two
structures in that region were in contact in the dark. Lowe13
pointed out that the irides of some races (such as Chinese)
had a propensity for sticking against the lateral wall of the
angle even in the absence of inflammation. The contact can
possibly encourage PAS formation and, as the process con-
tinues, may be associated with creeping angle closure, a
condition in which PAS slowly advances forward circumfer-
entially, making the iris insertion appear to become more and
more anterior.14,15 Interestingly, the abnormal positioning of
the ciliary body was also found in some of our ‘normal’
controls. When compared with Pavlin et al.’s9 normal sub-
jects, the mean TCPD of our normal eyes was much smaller
(721 mm vs. 1122 mm). This may explain why PACG is more
common in Chinese.1
To conclude, we have demonstrated the occurrence appo-
sitional angle closure after laser iridotomy in over half of our
patients. This is associated with relatively anteriorly posi-
tioned ciliary processes in people who have suffered APAC.
Although this is a relatively small series, our observation is
supported by the work of Mizuno et al.,16 Marchini et al.17 and
Sekhar et al.18 in other ethnic groups. We also provide addi-
tional support for the hypothesis advanced by Lowe19 and
Salmon20,21 who have previously argued in favour of anterior
position and rotation of the ciliary processes in chronic angle
closure glaucoma. The prevalence of the condition may offer
a possible explanation as to why PACG is more common in
Chinese and why a high proportion of eyes with APAC
develops an increase in IOP on long-term follow up despite
the presence of a patent LPI.3 In terms of the clinical man-
agement of APAC patients, our results have also suggested
the importance of long-term regular monitoring of intraoc-
ular pressure, angle status and the development of glaucoma-
tous optic neuropathy in patients who have received laser
iridotomy after APAC. Further studies are required to eluci-
date whether other factors, such as gravity, can contribute
to the formation of appositional angle closure and PAS.
Much innovation is needed to explore a desirable and defin-
itive treatment for this condition.
ACKNOWLEDGEMENT
This study was supported in part by Action for Vision Eye
Foundation, Hong Kong.
Yeung et al.
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