A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Glaucoma Panel: Sunita Radhakrishnan, MD,1 Philip P. Chen, MD,2 Anna K. Junk, MD,3 Kouros Nouri-Mahdavi, MD, MS,4 Teresa C. Chen, MD5
Ophthalmology, In Press © 2018 by the American Academy of Ophthalmology. Click here for free access to the OTA.
Purpose: To examine the efficacy and complications of laser peripheral iridotomy (LPI) in subjects with primary angle closure (PAC).
Methods: Literature searches in the PubMed and Cochrane databases were last conducted in August 2017 and yielded 300 unique citations. Of these, 36 met the inclusion criteria and were rated according to the strength of evidence; 6 articles were rated level I, 11 articles were rated level II, and 19 articles were rated level III.
Results: Reported outcomes were change in angle width, effect on intraocular pressure (IOP) control, disease progression, and complications. Most of the studies (29/36, 81%) included only Asian subjects. Angle width (measured by gonioscopy, ultrasound biomicroscopy, and anterior segment OCT) increased after LPI in all stages of angle closure. Gonioscopically defined persistent angle closure after LPI was reported in 2% to 57% of eyes across the disease spectrum. Baseline factors associated with persistent angle closure included narrower angle and parameters representing nonpupillary block mechanisms of angle closure, such as a thick iris, an anteriorly positioned ciliary body, or a greater lens vault. After LPI, further treatment to control IOP was reported in 0%-8% of PAC suspect (PACS), 42% to 67% of PAC, 21% to 47% of acute PAC (APAC), and 83%-100% of PAC glaucoma (PACG) eyes. Progression to PACG ranged from 0% to 0.3% per year in PACS and 0% to 4% per year in PAC. Complications after LPI included IOP spike (8–17 mmHg increase from baseline in 6%–10%), dysphotopsia (2%–11%), anterior chamber bleeding (30%–41%), and cataract progression (23%–39%).
Conclusions: Laser peripheral iridotomy increases angle width in all stages of primary angle closure and has a good safety profile. Most PACS eyes do not receive further intervention, whereas many PAC and APAC eyes, and most PACG eyes, receive further treatment. Progression to PACG is uncommon in PACS and PAC. There are limited data on the comparative efficacy of LPI versus other treatments for the various stages of angle closure; 1 randomized controlled trial each demonstrated superiority of cataract surgery over LPI in APAC and of clear lens extraction over LPI in PACG or PAC with IOP above 30 mmHg.
1 Glaucoma Center of San Francisco, Glaucoma Research and Education Group, San Francisco, California.
2 Department of Ophthalmology, University of Washington, Seattle, Washington.
3 Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida and Miami Veterans Affairs Healthcare System, Miami, Florida.
4 Stein Eye Institute, Los Angeles, California.
5 Harvard Medical School, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary, Glaucoma Service, Boston, Massachusetts.