Primary Angle-Closure Disease Preferred Practice Pattern®

Background Primary angle closure disease (PACD) is classified into several groups. Primary angle closure suspect is defined as ≥ 180 degrees of iridotrabecular contact (ITC) without intraocular pressure (IOP) elevation, peripheral anterior synechiae (PAS), or optic nerve damage. An eye with ≥ 180 degrees of ITC and elevated IOP or PAS is categorized as primary angle closure, and the additional presence of glaucomatous optic neuropathy indicates primary angle closure glaucoma. Acute angle-closure crisis (AACC) represents a sudden, marked IOP elevation with complete ITC. Plateau iris configuration is defined as a narrow angle due to an anteriorly positioned ciliary body with a deep central anterior chamber, and plateau iris syndrome is persistent ITC after laser peripheral iridotomy (LPI). Although 90% of cases of AACC present unilaterally, PACD is generally bilateral. Risk factors for PACD include Asian descent, hyperopia, older age, female gender, short axial length, and thick and anteriorly positioned crystalline lens. Rationale for Treatment Pupillary block is involved in the pathogenesis of PACD in most cases, and is resolved with LPI. Patients experiencing AACC should receive medical treatment to lower the IOP, and LPI should subsequently be performed in both eyes. Lens extraction has also been shown to be an effective treatment in some patients with primary angle closure and primary angle closure glaucoma. Care Process The goals of managing patients with PACD are to reverse or prevent angle closure and to control IOP to prevent glaucomatous optic nerve damage. Dark-room dynamic gonioscopy should be performed to diagnose PACD and verify improvement in angle configuration following treatment. Ultrasound biomicroscopy and anterior segment optical coherence tomography can also aid in the diagnosis of PACD.