ICO International Clinical Guidelines:
Primary Angle Closure (Initial Evaluation and Therapy)
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- Initial exam history
- Initial physical exam
- Diagnosis
- Management plan for patients in whom iridotomy is indicated
- Surgery and postoperative care for iridotomy patients
- Evaluation and follow-up of patients with iridotomy
- Education for patients if iridotomy is not performed
Initial Exam History (Key elements)
- Systemic history (e.g., use of topical or systemic medications) [A:III]
- Ocular history (symptoms suggestive of intermittent angle-closure attacks) [A:III]
- Family history of acute angle-closure glaucoma [B:II]
Initial Physical Exam (Key elements)
- Visual acuity [A:III]
- Refractive status [A:III]
- Pupils [A:III]
- Slit-lamp biomicroscopy [A:III]
- Anterior chamber inflammation suggestive of a recent or current attack
- Corneal edema
- Central and peripheral anterior- chamber depth
- Iris atrophy, particularly sector types, posterior synechiae or mid-dilated pupil
- Signs of previous angle closure attacks
- Anterior chamber inflammation suggestive of a recent or current attack
- Measurement of IOP [A:III]
- Gonioscopy of both eyes [A:III]
- Evaluation of fundus and optic nerve head using direct ophthalmoscope or biomicroscope [A:III]
Diagnosis
Management Plan for Patients in Whom Iridotomy is Indicated
- Treat acute PAC by laser iridotomy or incisional iridectomy if a laser iridotomy cannot be successfully performed. [A:III]
- In acute angle-closure attacks, usually use medical therapy first to lower the IOP, to reduce pain and clear corneal edema in preparation for iridotomy. [A:III]
- Perform prophylactic iridotomy in fellow eye if chamber angle is anatomically narrow. [A:II]
- Perform surgery on one eye at a time for patients requiring bilateral incisional iridectomy (several days apart) whenever feasible to avoid simultaneous bilateral complications. [A:III]
Surgery and Postoperative Care for Iridotomy Patients
- Ensure the patient receives adequate postoperative care. [A:III] Plan prior to and after surgery includes:
- Informed consent [A:III ]
- At least one preoperative evaluation by the surgeon [A:III]
- At least one IOP check within 30 to 120 minutes following laser surgery [A:II]
- Use of topical anti-inflammatory agents in the postoperative period, unless contraindicated [A:III]
- Informed consent [A:III ]
- Follow-up evaluations include:
- Evaluation of patency of iridotomy [A:III]
- Measurement of IOP [A:III]
- Gonioscopy, if not performed immediately after iridotomy [A:III]
- Pupil dilation to reduce risk of posterior synechiae formation [A:III]
- Fundus examination as clinically indicated [A:III]
- Evaluation of patency of iridotomy [A:III]
- Use medications perioperatively to avert sudden IOP elevation, particularly in patients with severe disease. [A:III]
- Refer for and encourage patients with significant visual impairment or blindness to use vision rehabilitation and social services. [A:III]
Evaluation and Follow-up of Patients with Iridotomy:
- After iridotomy, follow patients with glaucomatous optic neuropathy as specified in the Primary Open-Angle Glaucoma PPP. [A:III]
- Follow all other patients as specified in the Primary Open-Angle Glaucoma Suspect PPP. [A:III]
Education for Patients if Iridotomy is not Performed:
- Inform patients at risk for acute angle closure about symptoms of acute angle-closure attacks and instruct them to notify immediately if symptoms occur. [A:III]
- Warn patients of danger of taking medicines that could cause pupil dilation and induce an angle-closure attack. [A:III]
* Adapted from the American Academy of Ophthalmology Summary Benchmarks, November 2006 (www.aao.org)
(Download this Guideline as a PDF file - 101 KB)
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