• AAO PPP Glaucoma Panel, Hoskins Center for Quality Eye Care
    Compendium Type: I

    By the American Academy of Ophthalmology Preferred Practice Pattern Glaucoma Panel: Bruce E. Prum, Jr., MD,1 Leon W. Herndon, Jr., MD,2 Sayoko E. Moroi, MD, PhD,3 Steven L. Mansberger, MD, MPH,4 Joshua D. Stein, MD, MS,Michele C. Lim, MD,6 Lisa F. Rosenberg, MD,7 Steven J. Gedde, MD,8 Ruth D. Williams, MD9

    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 journal's PPP Collection page.

    1 Department of Ophthalmology, University of Virginia Health System, Charlottesville, Virginia
    2 Duke Eye Center, Duke University Medical Center, Durham, North Carolina
    3 W.K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
    4 Legacy Devers Eye Institute, Portland, Oregon
    5 W.K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
    6 UC Davis Eye Center, University of California, Davis, Sacramento, California
    7 Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
    8 Bascom Palmer Eye Institute, University of Miami, Miami, Florida
    9 Wheaton Eye Clinic, Wheaton, Illinois


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

    • Primary angle-closure suspect (≥180 degrees iridotrabecular contact (ITC), normal intraocular pressure [IOP], and no optic nerve damage)
    • Primary angle closure (≥180 degrees ITC with peripheral anterior synechiae [PAS] or elevated IOP, but no optic neuropathy)
    • Primary angle-closure glaucoma (≥180 degrees ITC with PAS, elevated IOP, and optic neuropathy)
    • Acute angle-closure crisis (AACC; occluded angle with symptomatic high IOP)
    • Plateau iris configuration (any ITC persisting after a patent laser peripheral iridotomy [LPI]) or syndrome (any ITC persisting after a patent LPI with pressure elevation after dilation)

    The management of other secondary forms of angle closure (e.g., iris bombé) is not discussed in this PPP.

    Common risk factors for PAC include Asian descent; hyperopia; older age; female gender; short axial length; and the size, shape, or position of the crystalline lens.

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

    Dark-room dynamic gonioscopy (as described in the subsection Gonioscopy in the Diagnosis section) should be performed to diagnose angle-closure disease and to verify improvement in angle configuration following treatment.

    Patients experiencing AACC should receive aqueous suppressants to lower the IOP acutely and laser iridotomy or iridectomy. After addressing the episode of AACC, it is important to perform LPI in the fellow eye when indicated.