Primary Angle-Closure Glaucoma

Publication Date: November 12, 2015
Last Updated: March 14, 2022

Recommendations

Patients with PAC may have elevated IOP as a result of a chronic compromise of aqueous outflow due to appositional or synechial angle closure, or from damage to the trabecular meshwork after previous intermittent AACC. Iridotomy is indicated for eyes with PAC or PACG.
  • This may be performed using either a thermal or neodymium yttrium-aluminum-garnet (Nd:YAG) laser.
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A growing body of evidence indicates that cataract extraction alone may lead to substantial IOP lowering in some PACG patients and can be considered as an option for treatment.
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In AACC, medical therapy is usually initiated first to lower the IOP, to reduce pain and to clear corneal edema. Iridotomy should then be performed as soon as possible.
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Laser iridotomy is the preferred surgical treatment because it has a favorable risk-benefit ratio.
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When laser iridotomy is not possible or if the AACC cannot be medically broken, LPI (even with a cloudy cornea), paracentesis, and incisional iridectomy remain effective alternatives.
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Follow-up 

The fellow eye of a patient with AACC should be evaluated, because it is at high risk for a similar event. The fellow eye should be scheduled for a prophylactic laser iridotomy promptly if the chamber angle is anatomically narrow, since approximately half of fellow eyes of acute angle-closure patients can develop AACCs within 5 years.
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  • These attacks can occur within days of presentation and, therefore, an ophthalmologist should consider LPI in the fellow eye as soon as possible.
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Eyes with recurrent high IOP after iridotomy when the pupil is dilated (plateau iris syndrome) should undergo further therapy, including iridoplasty, chronic miotic therapy, or other surgical procedures.
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With or without glaucomatous optic neuropathy, patients with a residual open angle or a combination of open angle and some PAS should be followed at appropriate intervals to check for increasing PAS.
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Provider and Setting 

The performance of certain diagnostic procedures (e.g., tonometry, perimetry, pachymetry, anterior segment imaging, optic disc imaging, and photography) may be delegated to appropriately trained and supervised personnel. However, the interpretation of results and medical and surgical management of disease require the medical training, clinical judgment, and experience of the ophthalmologist.
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Recommendation Grading

Overview

Title

Primary Angle-Closure Glaucoma

Authoring Organization

Publication Month/Year

November 12, 2015

Last Updated Month/Year

August 16, 2023

Supplemental Implementation Tools

Document Type

Other

Country of Publication

US

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Source Citation

Prum, Bruce E., Leon W. Herndon, Sayoko E. Moroi, Steven L. Mansberger, Joshua D. Stein, Michele C. Lim, Lisa F. Rosenberg, Steven J. Gedde, and Ruth D. Williams. "Primary Angle Closure Preferred Practice Pattern® Guidelines." Ophthalmology 123, no. 1 (2016): P1-P40. 

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
221
Literature Search Start Date
March 1, 2019
Literature Search End Date
June 1, 2020