Primary Angle-Closure Disease PPP 2020

By the American Academy of Ophthalmology Preferred Practice Pattern Glaucoma Committee: Steven J. Gedde, MD,¹ Philip P. Chen, MD,² Kelly W. Muir, MD,³ Kateki Vinod, MD,⁴ John T. Lind, MD,⁵ Martha M. Wright, MD,⁶ Tianjing Li, MD, MHS, PhD,⁷ Steven L. Mansberger, MD, MPH⁸

As of November 2015, the PPPs are initially published online-only in the Ophthalmology Journal and may be freely downloaded in their entirety by all visitors. Open the PDF for this entire PPP or click here to access the PPP on the journal's site. Click here to access the journal's PPP collection page.

¹Bascom Palmer Eye Institute, Miami, Florida

²Professor and Grace E. Hill Chair, Department of Ophthalmology, University of Washington, Chief of Ophthalmology, UW Medicine Eye Institute, Seattle, Washington

³Duke University School of Medicine, Department of Ophthalmology, Durham, North Carolina

⁴Department of Ophthalmology, Icahn School of Medicine at Mount Sinai and New York Eye and Ear Infirmary of Mount Sinai, New York, New York

⁵Indiana University School of Medicine, Department of Ophthalmology, Indianapolis, Indiana

⁶Minneapolis VA Medical Center, Minneapolis, Minnesota

⁷Associate Professor, Department of Ophthalmology, School of Medicine, Department of Epidemiology, School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado 

⁸Legacy Devers Eye Institute, Portland, Oregon

Highlighted Findings and Recommendations for Care

Understanding the current disease definition is important in the management of the primary angle-closure disease (PACD) spectrum. Modern classification includes: 

• Primary angle-closure suspect (PACS): >180 degrees iridotrabecular contact (ITC), normal intraocular pressure (IOP), and no optic nerve damage
• Primary angle-closure (PAC): >180 degrees ITC with peripheral anterior synechiae (PAS) or elevated IOP but no optic neuropathy
• Primary angle-closure glaucoma (PACG): >180 degrees ITC with PAS, elevated IOP, and optic neuropathy
• Acute angle-closure crisis (AACC): occluded angle with symptomatic high IOP
• Plateau iris configuration: narrow angle due to an anteriorly positioned ciliary body, with deep central anterior chamber
• Plateau iris syndrome: narrow angle due to an anteriorly positioned ciliary body, with deep central anterior chamber, and any ITC persisting after patent peripheral iridotomy

Common risk factors for PACD include Asian descent, hyperopia, older age, female gender, short axial length, and thick and anteriorly positioned crystalline lens. 

Dark-room dynamic gonioscopy should be performed to diagnose PACD and to verify improvement in angle configuration following treatment. Ultrasound biomicroscopy (UBM) and anterior segment optical coherence tomography (AS-OCT) can also aid in the diagnosis of angle closure, but only UBM and dynamic gonioscopy can identify the etiology of plateau iris.

The clinical signs and symptoms of AACC include pressure-induced corneal edema (experienced as blurred vision and occasionally as halos around lights), a mid-dilated pupil, vascular congestion (i.e., conjunctival and episcleral), eye pain, headache, and nausea/vomiting.

Patients experiencing AACC should receive medical treatment, including aqueous suppressants, parasympathomimetics, and osmotic agents, if necessary, to lower the IOP acutely and relieve symptoms. This should be followed by laser iridotomy or iridectomy. After addressing the episode of AACC, it is important to perform laser iridotomy in the fellow eye when indicated. 

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