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
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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.
Lens extraction is an effective treatment for some patients with PAC and PACG.