Consensus 3

3rd Consensus Meeting:
Angle Closure and Angle Closure Glaucoma

Hollywood, FL, May 3, 2006

cons3

edited by Robert N. Weinreb and David S. Friedman
2006. xiv and 98 pages with 59 figures of which 3 in color, 1 table. Hardbound.
ISBN-10: 90 6299 210 2
ISBN-13: 978-90-6299-210-2
Published by Kugler Publications.
Click here for more information on all publications in the Consensus series.

See meeting photos

Consensus statements

Epidemiology, Classification and Mechanism

Classification

  • The proposed classification scheme can be used not only to classify the
    natural history of angle closure, but also to determine prognosis and describe
    an individual’s need for treatment at different stages of natural history of
    the disease.
  • Additional clinical sophistication can be gained describing sequelae of
    angle closure affecting the cornea, trabecular meshwork, iris, lens optic disc
    and retina. Specifically, the extent of PAS, level of presenting IOP (in asymptomatic
    cases) and presence of glaucomatous optic neuropathy should be noted.
  • Ascertaining the mechanism of angle closure (pupillary block, plateau, lens-related,
    retro-lenticular) is essential for management, and it should be used in conjunction
    with a classification of the stage of the disease.
    Comment: Further refinement of these systems (such as the inclusion of
    symptoms as a defining feature of angle closure) should be made on the basis
    of peer-reviewed evidence.
    Comment: Angle closure can be caused by one or a combination of abnormalities
    in the relative or absolute sizes or positions of anterior segment structures
    or abnormal forces in the posterior segment that may alter the anatomy of the
    anterior segment. Angle closure may be understood by regarding it as resulting
    from blockage of the trabecular meshwork caused by forces acting at four successive
    anatomic levels: the iris (pupillary block), the ciliary body (plateau iris),
    the lens (phacomorphic glaucoma), and vectors posterior to the lens (malignant
    glaucoma).
  • Although the amount of pupillary block may vary among eyes with angle closure,
    all eyes with angle closure require treatment with iridotomy.

Gonioscopy

  • Gonioscopy is indispensable to the diagnosis and management of all forms
    of glaucoma and is an integral part of the eye examination.
  • An essential component of gonioscopy is the determination that iridotrabecular
    contact is either present or absent. If present, the contact should be judged
    to be appositional or synechial (permanent).
    Comment: The terms ‘iridotrabecular contact (stating the number of degrees)’
    and ‘primary angle closure suspect’ should be substituted for ‘occludable’,
    as this is more accurate.
    Comment: The determination of synechial contact may require indentation
    of the cornea during gonioscopy, in which case a goniolens with a diameter smaller
    than the corneal diameter is preferred.
  • Access to a magnifying, Goldmann-style lens enhances the ability to identify
    important anatomical landmarks, and signs of pathology. Although the accuracy
    of indentation with this lens has not been validated, its use does complement
    that of a goniolens with a diameter smaller than the corneal diameter. The ideal
    standard is access to both types of lens.
  • Anterior segment imaging devices may augment the evaluation of the anterior
    chamber angle, but their place in clinical practice still needs to be determined.
  • It is desirable to record gonioscopic findings in clear text. Describing
    the anatomical structures seen, the angle width, the iris contour and the amount
    of pigmentation in the angle are all desirable.

Management of Acute Angle Closure Crisis

  • Laser iridotomy should be performed as soon as feasible in the affected
    eye(s), and should also be performed as soon as possible in the contralateral
    eye.
  • Medical management is the recommended first step in treating acute angle
    closure, but the results of studies comparing this to immediate laser surgery
    are not yet available.
  • Laser iridoplasty can be effective at breaking acute attacks and should
    be considered if an attack cannot be broken by other means.
  • Paracentesis should be reserved for cases where other approaches have failed.
  • Primary cataract extraction may be a treatment option, but data supporting
    its use are limited.

Surgical Management of Primary Angle Closure Glaucoma

  • Laser peripheral iridotomy is recommended as the primary procedure in eyes
    with PACG.
    Comment: LPI can be performed easily on an outpatient basis and patients
    can then be monitored for response to treatment. This will allow time to undertake
    elective surgery in those with uncontrolled IOP, those with advanced disease
    or with co-existing cataract. LPI also serves as prophylaxis against acute angle
    closure.
  • There is lack of evidence for recommending primary incisional surgery (without
    laser PI) in eyes with PACG.
  • Trabeculectomy may be performed to lower IOP in eyes with chronic PAC (G)
    insufficiently responsive to laser or medical therapy.
  • There is insufficient evidence for deciding which cases with PACG should
    undergo cataract surgery alone (without trabeculectomy).
    Comment: Cataract surgery alone may be considered in eyes with mild degree
    of angle closure (less then 180 degrees of PAS), mild optic nerve/visual field
    damage or those that are not on maximal tolerated medical therapy.
  • There is lack of evidence for recommending lens extraction alone in eyes
    with more advanced PACG.
    Comment: Published studies to date have been non-randomized with small
    sample sizes and short follow up.
  • Combined cataract and glaucoma surgery in certain eyes may be useful to
    control IOP and restore vision.
    Comment: There is limited published evidence about the effectiveness
    of combined cataract extraction and trabeculectomy in eyes with PACG. There
    is a need for studies comparing this form of surgery with separately staged
    cataract extraction and trabeculectomy
  • There is limited evidence about the effectiveness of goniosynechialysis
    in the management of PACG.

Laser and Medical Treatment of Primary Angle Closure Glaucoma

  • Laser iridotomy should be performed in all eyes with an acute episode of
    angle closure, the contralateral fellow of all such eyes, and in eyes with established
    angle closure causing raised intraocular pressure and/or peripheral anterior
    synechiae. Eyes with anatomically narrow angles and typical symptoms of angle
    closure should also be treated. Consideration can be given to laser iridotomy
    in eyes with iridotrabecular apposition.
  • Iridoplasty can be considered in eyes with residual appositional closure
    provided a patent iridotomy is present. • Medical treatment should not be used
    as a substitute for laser iridotomy or surgical iridectomy in patients with
    PAC or PACG.
  • Iridoplasty is as effective as pressure lowering medication in controlling
    intraocular pressure in people with an acute attack of angle closure.
  • Iridoplasty is successful in relieving appositional closure due to plateau
    iris configuration in asymptomatic cases.
    Comment: Additional data in larger numbers of patients are needed.
    Comment: Iridoplasty may also have a role in managing cases of phacomorphic
    and pseudo-plateau iris configuration caused by iris cysts.

Laser and Medical Treatment of Primary Angle Closure Glaucoma

  • Medical treatment should not be used as a substitute for laser iridotomy
    or surgical iridectomy in patients with PAC or PACG.
  • Prostaglandin analogues appear to be the most effective medical agent in
    lowering IOP following laser iridotomy, regardless of the extent of synechial
    closure.

Detection of Primary Angle Closure and Angle Closure Glaucoma

  • Angle closure case detection or opportunistic screening should be performed
    in all persons forty years of age and older undergoing an eye examination.
  • Given the low specificity of the flashlight test, it is not recommended
    for use in population-based screening or in the clinic.
  • A shallow anterior chamber is strongly associated with angle closure. The
    use of ACD for population-based screening is as yet unproven.
  • Many clinicians currently perform iridotomy as prophylaxis in the presence
    of any visible iridotrabecular contact.
    Comment: Published evidence is lacking to justify this practice since
    it is unknown whether LPI is effective at preventing AAC, PAC, and PACG from
    developing in individuals with gonioscopically detected iridotrabecular contact.
    Comment: Research is needed to determine racial/ethnic variations in
    response to iridotomy.
    Comment: Evidence is needed to evaluate the meaning of a shallow LACD
    in the presence of an ‘open’ angle on gonioscopy.
  • There is currently no evidence in the literature supporting the standard
    use of provocative tests for angle closure. A negative provocative test does
    not exclude angle closure.

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