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  • Missed Opportunities to Prevent Acute Angle-Closure

    By Jean Shaw
    Selected and reviewed by Neil M. Bressler, MD, and Deputy Editors
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    Journal Highlights

    JAMA Ophthalmology, June 2022

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    How often do clinicians miss oppor­tunities to diagnose and treat acute angle-closure crisis (AACC)? Wu et al. set out to identify Medicare patients who presented with AACC and assess factors that may have raised their risk of developing it. They found that there appear to have been multiple opportu­nities for interventions that may have averted AACC.

    For this population-based retro­spective cohort study, the researchers included a 20% nationwide sample of Medicare beneficiaries (n = 1,179). Patients aged 40 years or older with AACC were identified with billing codes. A two-year lookback period from the point of patients’ initial pre­sentation with AACC was used to iden­tify those who had at last one eye care visit, received a diagnosis of open-angle glaucoma (OAG), or received at least one medication associated with risk of developing AACC (e.g., selective serotonin reuptake inhibitors, mono­amine oxidase inhibitors, antihista­mines, carbonic anhydrase inhibitors, and topiramate). In addition, among patients who had at least one eye care visit, the researchers identified those who either had undergone gonioscopy or were diagnosed with an anatomic narrow angle before developing AACC.

    The mean age of those with AACC was 66.7 years (range, 40-96 years), and 766 (65%) were women. With regard to race, the majority (n = 791; 67.1%) were White. A total of 464 individ­uals (39.4%) had OAG or suspected OAG, and 414 (35.3%) had received a medication associated with increased risk of AACC before they developed the condition.

    With regard to eye care, 796 of the 1,179 patients (67.5%) had consulted an ophthalmologist or optometrist during the two-year lookback period; the remainder had received no eye care during this time. Of those who were examined, 264 (33.2%) underwent gonioscopy in the two years preceding their diagnosis with AACC. Of those who had gonioscopy, 113 (42.8%) received a diagnosis of an anatomic narrow angle.

    In their discussion, the authors not­ed that the results highlight multiple missed opportunities for interventions to prevent AACC. They recommend addressing risk factors associated with the underuse of eye care as well as addi­tional emphasis on correct gonioscopy technique, greater use of gonioscopy to identify patients with eyes at risk, and prophylactic laser peripheral iridotomy when indicated. (Also see related com­mentary by Alexander C. Day, PhD, and Gus Gazzard, MA, MD, MBBChir, in the same issue.)

    The original article can be found here.