Treatment of Angle-Closure Glaucoma

Introduction to Angle-Closure Glaucoma

Angle-closure glaucoma is characterized by appositional or synechial closure of the anterior chamber angle, and pupillary block as a key element in pathogenesis, causing anterior bowing of the iris, with the American Academy of Ophthalmology providing guidance on diagnosis and treatment 1
The American Academy of Ophthalmology recommends against using Durysta (bimatoprost implant) for chronic angle-closure glaucoma, as it is only FDA-approved for open-angle glaucoma and ocular hypertension, and could potentially worsen angle-closure conditions 2, 1

The American Academy of Ophthalmology recommends laser peripheral iridotomy (LPI) as the first-line treatment for chronic angle-closure glaucoma, creating a bypass channel for aqueous flow and eliminating pupillary block 3, 1
Lens extraction is recommended as a second-line treatment, particularly in older patients with coexisting cataract, as it can reduce intraocular pressure (IOP) by deepening the anterior chamber, with the American Academy of Ophthalmology recommending consideration of surgical options to achieve optimal outcomes 3, 1
Medical therapy, including beta-blockers, alpha2-adrenergic agonists, and carbonic anhydrase inhibitors, should only be considered after patent iridotomy has been performed and confirmed, with the American Academy of Ophthalmology recommending their use to lower IOP and prevent damage to the optic nerve 3, 1
Prostaglandin analogues may be considered only after iridotomy has been performed and confirmed patent, for medication therapy after iridotomy, as recommended by the American Academy of Ophthalmology 1

Regular gonioscopy is essential to monitor for increasing peripheral anterior synechiae, with the American Academy of Ophthalmology recommending regular evaluation to monitor for potential complications 3
Topical corticosteroids should be prescribed in the postoperative period to reduce inflammation in patients after iridotomy, with the American Academy of Ophthalmology recommending their use to minimize complications 3
Intraocular pressure should be measured before and after the procedure to detect any sudden elevations, with the American Academy of Ophthalmology recommending regular monitoring to ensure optimal outcomes 3
The patency of the iridotomy should be confirmed by visualizing the flow of aqueous and pigment from the posterior to the anterior chamber, with the goal of ensuring optimal drainage and preventing complications, as recommended by the American Academy of Ophthalmology 3

Surgical interventions including trabeculectomy or tube shunt surgery may be considered for refractory cases, with the American Academy of Ophthalmology recommending consideration of surgical options to achieve optimal outcomes 1
Cataract extraction may be considered to reduce IOP in patients with glaucoma, especially in older patients, with the American Academy of Ophthalmology recommending consideration of surgical options to achieve optimal outcomes 3, 1

The American Academy of Ophthalmology recommends immediate medical therapy to lower intraocular pressure (IOP) in patients with acute angle-closure glaucoma (AACG), followed by definitive treatment with laser peripheral iridotomy (LPI) as soon as possible, with the goal of rapidly lowering IOP to relieve symptoms and clear corneal edema, making subsequent laser treatment possible 1, 3
Aqueous suppressants, such as beta-adrenergic antagonists, alpha2-adrenergic agonists, and carbonic anhydrase inhibitors, may be used to lower IOP in patients with AACG, with the American Academy of Ophthalmology recommending their use as part of a comprehensive treatment approach 1
Apraclonidine may be used to prevent IOP spikes during and after laser procedures, such as laser peripheral iridotomy, and can be used before and after laser procedures to maintain stable IOP, with the American Academy of Ophthalmology recommending its use as part of ongoing medical therapy after successful LPI if IOP remains elevated 4, 5, 1

Prophylactic LPI should be performed promptly in the fellow eye if the chamber angle is anatomically narrow, as approximately half of fellow eyes develop AACG within 5 years, with the American Academy of Ophthalmology recommending prompt intervention to prevent angle-closure glaucoma 1, 3
Prophylactic LPI should be performed as soon as possible, as attacks can occur within days of the initial presentation, with the American Academy of Ophthalmology recommending prompt intervention to prevent complications 1, 3, 4, 5

Potential complications of iridotomy include increased IOP, corneal burns, late-onset corneal edema, development of posterior synechiae, hyphema, iritis, and ocular dysphotopsias, with the American Academy of Ophthalmology recommending prompt recognition and treatment to minimize damage 3
Surgical interventions for complications or occluded iridotomy may include iridoplasty, goniosynechialysis, trabeculectomy, or tube implantation, with the American Academy of Ophthalmology recommending prompt intervention to restore patency and prevent complications 3