This protocol applies to the patient who was managed as a Primary Angle-Closure Suspect (PACS), underwent laser peripheral iridotomy (LPI), and yet — on repeat gonioscopy — the anterior chamber angle has not opened. ≥180 degrees of iridotrabecular contact (ITC) persists, with no intraocular pressure elevation, no peripheral anterior synechiae, and no glaucomatous optic neuropathy.
Gonioscopy confirms ≥180 degrees of iridotrabecular contact (ITC). Intraocular pressure is within normal limits, peripheral anterior synechiae (PAS) are absent, and there is no evidence of glaucomatous optic neuropathy — fulfilling the definition of a Primary Angle-Closure Suspect with persistent anatomical risk despite prior intervention.
The preceding step for Primary Angle-Closure Suspect (PACS) was laser peripheral iridotomy (LPI), performed to reduce the risk of acute angle-closure crisis and progression. The required outcome — an open anterior chamber angle confirmed on repeat gonioscopy — was not achieved. This protocol defines the management step that follows that failure.
When LPI has not resolved the iridotrabecular contact, management advances to a pharmacological strategy directed at intraocular pressure. The specific agents indicated for this setting, and the complete approach, are detailed in the structured protocol below.
Primary angle-closure suspect (PACS): ≥180 degrees iridotrabecular contact (ITC) without intraocular pressure (IOP) elevation, peripheral anterior synechiae (PAS), or glaucomatous optic neuropathy
An eye with this amount or more of ITC, no PAS, normal IOP, and no glaucomatous optic neuropathy is considered a primary angle-closure suspect (PACS).
Some PACS patients develop increased IOP despite LPI and eventually require topical ocular hypotensive agents.
DOI: 10.1016/j.ophtha.2025.12.030
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