Consensus 12

12^th Consensus Meeting: Angle Closure and Angle Closure Glaucoma

Honolulu, HI, USA, June 24, 2025
Edited by: R.N. Weinreb, B. Xu, Xiulan Zhang
2025. Many photos and figures. Hardbound.
ISBN-13: 978-90-6299-336-9
Published by: Kugler Publications.
Click here for more information on all publications in the Consensus series.

See meeting photos

Leadership

• WGA Consensus Initiative Chair
  Robert N. Weinreb (USA)
• WGA Consensus 12 Co-Chairs
  Benjamin Xu (USA), David Friedman (USA), Paul Foster (UK), Tin Aung (Singapore), Xiulan Zhang (China)
• Section Leaders
  Ching-Yu Cheng (Singapore), Christopher Leung (Hong Kong), Clement Tham (Hong Kong), Do Tan (Vietnam), Gus Gazzard (UK), Kyung Rim Sung (Korea), Lisandro Sakata (Brazil), Mani Baskaran (India), Mingguang He (Hong Kong), Monisha Nongpiur (Singapore), Ningli Wang (China), Ronnie George (India), Sasan Moghimi (USA), Shan Lin (USA), Tanuj Dada (India), Vijaya Lingham (India)

Introduction

In the 19 years since the last World Glaucoma Association (WGA) consensus meeting on angle closure glaucoma (published in 2006), our understanding of this visually devastating disease has been significantly transformed by a series of landmark studies.

Population-based epidemiological research has shed new light on the global burden of primary angle closure glaucoma (PACG) and its associated ocular morbidity. Insights into disease pathogenesis have deepened, particularly regarding racial anatomical differences and dynamic iris-related mechanisms.

Anterior segment optical coherence tomography (AS-OCT) is emerging as a potential new standard for detecting and risk-stratifying angle closure, superseding gonioscopy, the long-standing clinical standard. The integration of artificial intelligence (AI) with AS-OCT has further enhanced its utility and accessibility for widespread clinical use.

At the same time, evidence-based care for angle closure disease has improved, driven by pivotal trials such as EAGLE and ZAP. These studies support a broader spectrum of treatment strategies, including clear lens extraction (CLE), goniosynechiolysis (GSL), and minimally invasive glaucoma surgeries (MIGS), and a reconsideration of which patients should be treated.

Given the depth and breadth of these advances, it is an ideal time is to synthesize current knowledge for the global glaucoma community and identify critical knowledge gaps to guide research over the next two decades.

As with all the previous WGA consensuses, the Angle Closure and Angle Closure Glaucoma Consensus is based on the published literature and expert experience. Although consensus does not replace and is not a surrogate for scientific investigation, it does provide considerable value, especially when the desired evidence is lacking. The goal of this consensus is to establish what we ‘know’ and what we need to ‘know’. It is expected that this consensus report will serve as a benchmark for our current knowledge and that it will be revised and improved with the emergence of new evidence.

Summary Consensus Points

• Section 1: Epidemiology
• Section 2: Pathophysiology and Risk Factors
• Section 3: Diagnosis and Evaluation
• Section 4: Medical and Laser Management
• Section 5: Surgical Management
• Section 6: Acute Primary Angle Closure

Section 1 – Epidemiology

Angle closure

1. Angle closure prevalence appears to be increasing due to population aging.
2. Angle closure appears to be more common in many Asian populations than in European-derived or African-derived populations.
   • More epidemiologic data are needed, particularly in African-derived populations.
3. Women and the elderly are at higher risk of angle closure.
4. The risk of progression from primary angle-closure suspect to primary angle closure is low for most primary angle closure suspect eyes.
   • There is a higher risk of progression from primary-angle closure suspect to primary angle closure with older age.
   • The low rate of progression in clinical trials is not consistent with the prevalence of primary angle-closure glaucoma in epidemiological studies.
5. Primary angle closure is a higher risk state for primary angle-closure glaucoma.
   • Data on the clinical significance of peripheral anterior synechiae are limited.

Primary angle-closure glaucoma

6. The number of individuals with primary angle-closure glaucoma is projected to rise.
   • Projections do not account for the increasing rates of cataract surgery and myopia prevalence, which are strongly protective against primary angle-closure glaucoma.
7. Primary angle-closure glaucoma is most common among individuals of Asian ancestry.
   • Data in non-Asians are limited.
8. As blindness is associated with over 25% of primary angle-closure glaucoma cases worldwide, a focus on detecting primary angle-closure disease (defined as primary angle closure or primary angle-closure glaucoma) at a treatable stage is needed to prevent vision loss from primary angle-closure glaucoma.
9. Primary angle-closure glaucoma can occur in myopic eyes, although the proportion varies by race and ethnicity.
   • Primary angle-closure glaucoma is uncommon in high myopes.
   • The relationship between myopia and angle closure depends on the effects on anterior segment biometrics more than overall axial length.

Future directions

• Data are sparse from individuals aged 70 years and older, which is a growing demographic group. Cross-sectional biometry in populations shows mean anterior chamber depth declines with age, peaking between 30 to 50 years of age. This decline slows and potentially reverses at age 70 years, but more research is needed.
• Further research is required to investigate individuals who may be at higher risk of progression from primary angle-closure suspect to primary angle closure, such as those with connective tissue abnormalities.

Section 2 – Genetics and Pathophysiology

1. First-degree relatives of individuals with spectrum of primary angle closure, defined as primary angle-closure suspect, primary angle closure, or primary angle-closure glaucoma, are at significantly higher risk of angle closure supporting its genetic basis.
   • Large-scale genome-wide association studies have identified genetic loci associated with primary angle-closure glaucoma.
   • Known genetic variants associated with primary angle-closure glaucoma have small effect sizes.
2. Evidence to recommend genetic testing for primary angle-closure disease, defined as primary angle closure or primary angle-closure glaucoma, is limited.
3. Risk conferred by hyperopic refractive error is secondary to its association with ocular biometrics, specifically shorter AL and shallower anterior chamber depth.
   • Anterior chamber depth alone does not explain racial and ethnic differences in angle-closure prevalence.
4. Pupillary block is the major mechanism, accounting for 75% of all primary angle closure.
5. Association studies suggest that dynamic changes in iris and choroidal volume are involved in the pathogenesis of primary angle-closure disease.
   • Choroidal effusion can be found in primary angle closure and primary angle-closure glaucoma eyes.
   • Primary angle-closure suspect, primary angle closure, and primary angle-closure glaucoma are associated with greater choroidal thickness.
   • Supraciliary effusion can result in anterior rotation of the ciliary body and angle closure.
   • Accumulation of aqueous in the vitreous cavity and greater resistance to fluid exchange across the anterior hyaloid can precipitate angle closure from aqueous misdirection (also sometimes termed vitreous block).
   • Malignant glaucoma is an ambiguous term that is not adequately descriptive of the disease process.
6. Vitreous block, collagen abnormalities, autonomic dysfunction, and zonulopathy likely contribute to angle-closure pathogenesis but are not directly measurable using available tools.

Future directions

• More research is needed on iris thickness, which has emerged as an important anatomical risk factor for primary angle-closure disease.
• Serial studies, including follow-up on the ZAP study cohort, are needed to establish the precise nature of the relationship between primary angle-closure glaucoma with dynamic changes in iris volume and choroidal volume.

Section 3 – Diagnosis and Evaluation

1. The definitions of spectrum of primary angle closure are based on gonioscopy and clinical findings:
   • Angle closure on gonioscopy is defined as when the posterior, usually pigmented, trabecular meshwork is not visible, possibly indicating the presence of iridotrabecular contact.
   • Primary angle-closure suspect: 2 or more quadrants of angle closure on gonioscopy.
   • Primary angle closure: primary angle-closure suspect plus peripheral anterior synechiae and/or elevated intraocular pressure, or an acute primary angle closure attack.
   • Primary angle-closure glaucoma: primary angle-closure suspect or primary angle closure plus glaucomatous optic neuropathy.
2. One way of characterizing the spectrum of primary angle closure is:
   • The term primary angle closure disease includes primary angle-closure and primary angle-closure glaucoma.
   • The term spectrum of primary angle closure includes primary angle-closure suspect and primary angle-closure disease.
3. Gonioscopy is the clinical standard for evaluating the anterior chamber angle. However, it is subjective and variable.
   • Gonioscopy is a vital but underutilized part of the eye exam.
   • The patient should be examined in a dark room and with the use of a short, narrow slit-beam to avoid constricting the pupil and artifactually opening the angle.
   • Indentation gonioscopy remains the gold standard for identifying peripheral anterior synechiae.
   • Tilting of the goniolens can be performed to visualize the angle recess in eyes with a high lens vault.
4. The Van Herick test of limbal anterior chamber depth only has moderate sensitivity or specificity in detecting eyes with gonioscopic angle closure and is not a replacement for gonioscopy.
   • Limbal anterior chamber depth can be used for opportunistic case detection when followed by gonioscopy but is less useful for population-based screening as it could generate an unacceptably high number of false positives.
5. Anterior segment optical coherence tomography and ultrasound biomicroscopy are adjunctive tools to gonioscopy for evaluating the anterior chamber angle.
   • Angle closure on anterior segment optical coherence tomography and ultrasound biomicroscopy is defined as presence of contact between the anterior iris surface and inner corneal curvature or angle wall anterior to the scleral spur, which indicates the presence of iridotrabecular contact.
   • Iridotrabecular contact can be described in terms of circumferential extent and anterior-posterior length (also referred to as height or width). There is no consensus about clinically significant thresholds in extent or length.
6. There may be disagreement between gonioscopy and anterior segment optical coherence tomography in detecting angle closure due to differences in definitions.
   • A wide range of factors, including anatomical configurations, examination techniques, refraction correction, level of ambient lighting, and pupillary constriction due to light or accommodation, contribute to the disagreement.
   • The extent of iridotrabecular contact on anterior segment optical coherence tomography is more strongly associated with primary angle-closure disease severity than cumulative gonioscopy grading.
7. Gonioscopy is poorly able to identify which primary angle-closure suspect eyes are at high risk for primary angle-closure disease.
   • Anterior segment optical coherence tomography measurements have been found to be associated with progression from primary angle-closure suspect to primary angle closure.
   • No precise iridotrabecular contact or measurement cutoffs have been demonstrated to be clinically significant or widely adopted for routine care.
   • Longitudinal studies assessing the clinical significance of anterior segment optical coherence tomography findings alone for risk stratifying primary angle-closure suspect eyes are needed.
8. Ultrasound biomicroscopy remains the gold standard for evaluating the ciliary body.
   • Newer anterior segment optical coherence tomography devices utilizing longer-wavelength swept-source lasers and image averaging provide reproducible visualization and analysis of the ciliary body in some eyes.
9. Plateau iris configuration is characterized by anteriorly positioned ciliary processes causing posterior angulation in the peripheral iris and the absence of the iridociliary sulcus.
   • Plateau iris syndrome is persistence of angle closure despite a patent iridotomy in the presence of plateau iris configuration.
10. Goniophotographs are useful to capture anatomical findings (e.g., iris nevus) but are not commonly used to evaluate the angle recess.
11. There is no consensus about which biometric parameters describing the anterior segment are the most clinically relevant for detecting individuals at high risk for primary angle-closure glaucoma.
    • Anterior chamber depth cutoffs have been tested but are not effective for identifying individuals at high risk for primary angle-closure glaucoma in the community.
    • Anterior chamber volume has better diagnostic performance in detecting angle closure compared to anterior chamber angle width parameters, such as angle opening distance.
12. There are no widely accepted provocative tests to identify individuals at high risk for primary angle-closure glaucoma.
    • The dark room prone provocative test is unable to risk-stratify primary angle-closure suspect for progression to primary angle-closure disease.

Section 4 – Management: Medical and Laser

General approach

1. Gonioscopy is an indispensable part of the ophthalmic examination.
   • Gonioscopy should be performed with indentation to differentiate appositional from synechial closure.
   • The Van Herick test is not a substitute for gonioscopy.
   • Anterior segment imaging modalities can be used to augment the clinical examination but are not a substitute for gonioscopy, as features such as trabecular pigmentation, angle recession, and neovascularization cannot be reliably identified using anterior segment optical coherence tomography or ultrasound biomicroscopy.
2. Long-term follow-up with gonioscopy in phakic eyes is needed, as age-related lens thickening can further narrow the angle, increasing the risk of primary angle-closure glaucoma.
3. Evaluation of the optic disc, visual field, and retinal nerve fiber layer is critical for detecting glaucomatous damage and progression.
4. An important goal of treatment in primary angle-closure disease is to alleviate iridotrabecular contact and prevent further impairment of aqueous drainage due to angle closure.
5. Even when the angle-closure process is controlled, further treatment may be necessary to avoid glaucoma progression.
   • Medications, lasers, and surgeries can recover or improve aqueous outflow in angle-closure eyes.

Medical treatment

6. In eyes with primary angle-closure disease, prostaglandin analogues are the most effective medical agent for intraocular pressure lowering regardless of the extent of synechial closure once pupillary block has been controlled.
7. Carbonic anhydrase inhibitors, beta blockers, and alpha-adrenergic agonists can be considered for second-line medical treatments.
   • Evidence on the intraocular pressure-lowering efficacy of Rho kinase inhibitors in angle closure is limited.
8. The role of miotics in primary angle closure is unclear.
   • Miotics generally should not be used long-term as intraocular pressure-lowering agents in angle-closure eyes.
   • Miotics should be used in cases of acute primary angle closure but may not be effective due to iris ischemia while the intraocular pressure is high.
   • Miotics may be considered for long-term use in plateau iris syndrome.
9. Cycloplegics should be considered in the setting of anterior chamber shallowing from secondary angle closure, such as aqueous misdirection.

Laser treatment

10. Laser peripheral iridotomy is used to relieve relative pupillary block, which is the main mechanism in most patients with angle closure.
    • Angle closure persists in around a quarter of post-laser peripheral iridotomy eyes.
    • Angle assessment (gonioscopy or anterior segment optical coherence tomography) should be performed post-laser peripheral iridotomy to assess the effect of LPI and identify other mechanisms, including plateau iris.
11. LPI is a safe procedure with very low risk of serious adverse events.
    • Sequential argon/Nd:YAG technique (argon first followed by Nd:YAG) requires less overall energy in patients with thick irides, specifically those of Asian and African descent or Hispanic ethnicity.
    • Laser peripheral iridotomy location near the lid margins should be avoided to reduce risk of dysphotopsias.
    • Laser peripheral iridotomy size should be a minimum of 200 μm in diameter.
    • There is an increased risk of intraocular pressure spikes when performing LPI in eyes with elevated intraocular pressure and 2 or more quadrants of peripheral anterior synechiae.
12. Laser peripheral iridotomy is not indicated in most primary angle-closure suspect eyes (ZAP and ANA-LIS trials), although risk assessment for progression is suboptimal.
    • Factors to be considered for performing laser peripheral iridotomy include, for example, history of primary angle-closure disease in the fellow eye, older age, positive family history of primary angle-closure glaucoma, need for frequent dilation (e.g., in diabetics or glaucoma suspects), limited access to care, and need for hemodialysis.
    • Biometric features associated with greater risk for progression include higher intraocular pressure, smaller AOD500, smaller limbal anterior chamber depth, and shallower anterior chamber depth.
13. In acute primary angle closure, laser peripheral iridotomy should be performed as soon as possible in the contralateral eye, which is at very high risk for a similar event.
14. Early lens extraction is an effective method of intraocular pressure lowering that is more cost-effective and results in better quality of life compared to laser peripheral iridotomy at certain stages of primary angle-closure disease (EAGLE trial).
    • Participants of the EAGLE trial were aged 50 years or older and had primary angle closure with intraocular pressure > 30 mmHg or primary angle-closure glaucoma.
    • Patients who do not fulfill the EAGLE criteria may still benefit from early lens extraction, although these data are lacking.
15. In acute primary angle closure, laser peripheral iridoplasty or laser pupilloplasty may help to break the attack prior to definitive treatment.
    • Laser peripheral iridoplasty widens the angle recess by contracting the iris away from the trabecular meshwork.
    • Laser pupilloplasty contracts the iris tissue near the pupil, creating a peaked pupil and relieving pupillary block.
16. Iridoplasty can widen the angle in eyes with plateau iris syndrome that have persistent appositional angle closure after laser peripheral iridotomy.
    • Evidence does not support improved long-term intraocular pressure control.
    • Iridoplasty is not useful for synechial angle closure.
    • Iridoplasty may be associated with adverse effects, such as pupillary dilation, corneal endothelial damage, and progressive peripheral anterior synechiae formation.
17. Selective laser trabeculoplasty can be effective for intraocular pressure reduction in angle-closure eyes that have had laser peripheral iridotomy and/or lens extraction, allowing for visual access to the trabecular meshwork.

Future directions

• Additional data are needed on the efficacy of laser peripheral iridotomy treatment in diverse populations, especially with demographics differing from those of the ZAP and ANA-LIS trials.
• Further studies are needed to identify features of individuals who may be poorly responsive to laser peripheral iridotomy treatment and should be considered for alternative treatments, such as lens extraction, instead.

Section 5 – Surgical Management

1. Lens extraction can lead to significant reduction in intraocular pressure and medication burden in primary angle-closure disease.
   • Lens extraction can effectively lower intraocular pressure regardless of whether the glaucoma is controlled or uncontrolled preoperatively.
   • Lens extraction alone may not achieve target intraocular pressure or medication-free control in those with poorly controlled primary angle-closure glaucoma and advanced disease.
   • Glaucoma surgery (e.g., trabeculectomy, minimally invasive glaucoma surgery) at the time of lens extraction may be indicated to achieve intraocular pressure control, particularly when the glaucoma is moderate to severe.
   • Lens extraction can alter visual field and optical coherence tomography results, necessitating a new baseline for subsequent glaucoma monitoring.
2. Lens extraction is an option as a first-line treatment for primary angle-closure glaucoma and primary angle closure with raised intraocular pressure (EAGLE trial).
   • Lens extraction demonstrated superior effectiveness in lowering intraocular pressure, medication needs, the rate of subsequent glaucoma surgeries, and was associated with better quality of life score compared to standard care with laser peripheral iridotomy and topical medications.
   • Phacoemulsification with intraocular lens placement in the capsular bag is the recommended method of lens extraction.
   • If phacoemulsification is not available, the benefits and risks of the available surgical techniques must be carefully evaluated.
3. There are inconclusive data on the benefit of phacoemulsification + goniosynechiolysis for better intraocular pressure lowering as compared to phaco alone in patients with primary angle-closure glaucoma, cataract, and peripheral anterior synechiae.
   • Evidence is inconclusive that phacoemulsification + goniosynechiolysis is superior to phacoemulsification alone in terms of intraocular pressure control, reduction of peripheral anterior synechiae, and the need for medications.
4. Combining phacoemulsification with goniosynechiolysis and minimally invasive glaucoma surgery, including goniotomy, may be more effective than phacoemulsification alone in reducing intraocular pressure in patients with primary angle-closure glaucoma.
   • Data are limited on the types of minimally invasive glaucoma surgery and the specific stages of primary angle-closure disease appropriate for this treatment.
   • Some minimally invasive glaucoma surgery devices are off-label for use in primary angle-closure disease.
   • Goniosynechiolysis may need to be performed to access the trabecular meshwork.
   • Phacoemulsification with goniosynechiolysis and goniotomy (phacogoniotomy) can be a viable option for intraocular pressure reduction in patients with primary angle-closure glaucoma and cataract.
   • One randomized controlled trial reported similar cumulative rates of surgical success between phacogoniotomy and phacotrabeculectomy in advanced primary angle-closure glaucoma eyes.
5. Trabeculectomy alone can provide effective intraocular pressure lowering in primary angle-closure glaucoma eyes, particularly in the pseudophakic eye.
   • In the phakic eye, trabeculectomy promotes cataract progression and there is an increased risk of shallow AC and iris incarceration in the sclerectomy.
   • Subsequent cataract surgery can increase the risk of bleb scarring.
6. Combining phacoemulsification with trabeculectomy (phacotrabeculectomy).
   • Phacotrabeculectomy is a viable option for primary angle-closure glaucoma eyes.
   • Phacotrabeculectomy addresses the underlying issue of a crowded anterior chamber or a bulky lens and reduces the risk of further shallowing of the anterior chamber.
7. Glaucoma drainage device implantation is typically reserved for primary angle-closure glaucoma eyes at higher risk for failure and/or complications than with other interventions or for those patients who have unsuccessful outcomes with other intraocular pressure-lowering surgeries.
   • Combined phacoemulsification and glaucoma drainage device implantation can be considered in eyes with significant cataract or very shallow anterior chamber due to a thick crystalline lens.
8. Cycloablation is an alternative treatment for the management of primary angle-closure glaucoma.
   • Results are variable and treatment often needs to be repeated.
   • It may be particularly useful when the patient wishes to avoid the risks of incisional surgery or is not systemically fit for or unable to access the operating room.
   • Large prospective randomized controlled trials on the use of cycloablation for primary angle-closure glaucoma are needed.
   • Endoscopic cyclophotocoagulation combined with phacoemulsification may provide greater intraocular pressure lowering than phacoemulsification alone.

Section 6 – Acute Primary Angle Closure

1. Acute primary angle closure is an ophthalmic emergency that can cause sudden, pronounced, but typically transient reduction in vision.
   • Acute primary angle closure typically presents with severe ocular pain, headache, nausea, and a fixed mid-dilated pupil.
   • Secondary causes of angle closure should be excluded.
   • Acute primary angle closure more commonly affects older individuals, women, and those of Asian descent.
   • A range of medications may precipitate acute primary angle closure, including those with adrenergic or anticholinergic effects. Careful medication review should be performed in at-risk individuals.
   • Acute primary angle closure usually occurs unilaterally. Systemic medications (such as anticonvulsants and antidepressants) and systemic disease (such as Vogt-Koyanagi-Harada syndrome) may cause bilateral acute primary angle closure.
2. Initial treatment with topical and systemic medications can lower the intraocular pressure, relieve pain, improve corneal clarity, and reduce inflammation.
   • Miotics should be used in cases of acute primary angle closure but may not be effective due to iris ischemia while the intraocular pressure is high.
   • Early administration of anti-inflammatory agents may facilitate a more rapid reduction in intraocular pressure.
3. Laser peripheral iridotomy should be performed as soon as possible.
   • If laser peripheral iridotomy is not possible due to corneal edema, anterior chamber paracentesis, diode laser, or laser peripheral iridoplasty, with or without laser pupilloplasty, can be performed.
   • If the iris is thick and there are no convenient iris crypts, argon laser pretreatment should be considered, followed by YAG:Nd laser peripheral iridotomy.
4. Anterior chamber paracentesis is an option for immediate intraocular pressure reduction and symptom relief in acute primary angle closure.
   • It is particularly useful when systemic intraocular pressure-lowering agents such as mannitol or acetazolamide are contraindicated or when laser peripheral iridotomy or laser peripheral iridoplasty cannot be performed. However, the procedure carries risks and should be performed with caution.
5. Lens extraction (once intraocular pressure and inflammation have been controlled) is the definitive treatment for acute primary angle closure, as it alleviates pupillary block, deepens the anterior chamber angle, lowers intraocular pressure, and improves vision.
   • Surgical challenges include corneal edema, a shallow anterior chamber, intraocular inflammation, and zonular weakness or dehiscence.
6. Surgical peripheral iridectomy can be performed in eyes with medically uncontrolled acute primary angle closure when an appropriate laser is unavailable, when laser peripheral iridotomy is not possible, or in cases with both severe corneal edema and a clear lens.
7. Trabeculectomy can be considered for uncontrolled intraocular pressure after acute primary angle closure resolution if there are extensive peripheral anterior synechiae after iridectomy or if the iridectomy could not be performed.
   • Phacoemulsification and combined goniosynechiolysis with or without goniotomy is an alternative to trabeculectomy.
8. Patients with spectrum of primary angle closure should be educated about acute primary angle closure symptoms and the need to see an eye care specialist urgently if they present.
9. There is no effective method to identify individuals at high risk for acute primary angle closure. The use of anterior segment imaging or polygenic risk score is unproven.
10. Additional research is needed to identify anatomical features predictive of acute primary angle closure.