This protocol addresses patients with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) in whom gonioscopy reveals ≥180 degrees of iridotrabecular contact (ITC), accompanied by peripheral anterior synechiae (PAS) and/or elevated intraocular pressure (IOP).
PAC is defined as ≥180° ITC with PAS and/or elevated IOP in the absence of glaucomatous optic neuropathy. PACG additionally involves glaucomatous optic neuropathy.
Laser peripheral iridotomy (LPI) — the preceding intervention for primary angle closure — was performed, but repeat gonioscopy did not confirm an open anterior chamber angle: the primary goal of that treatment. Persistent structural angle closure with significant ITC drives escalation to the next step.
The structured next-step involves a surgical, lens-based intervention. Whether it is performed alone or combined with additional intraoperative steps — and the criteria guiding that decision — are contained in the complete protocol.
Primary angle closure (PAC): ≥180 degrees ITC with PAS and/or elevated IOP but no glaucomatous optic neuropathy
Primary angle-closure glaucoma (PACG): ≥180 degrees ITC with PAS and/or elevated IOP and glaucomatous optic neuropathy
Therefore, earlier lens extraction, even if the lens is not visually significant, can be considered for the initial management of PAC with elevated IOP and PACG.
Although lens extraction alone has been shown to substantially lower IOP in PACD, the addition of goniosynechiolysis may help reduce the number of glaucoma medications needed and reduce the total amount of PAS.
Numerous studies document that lens extraction significantly widens the anterior chamber angle in eyes with PAC and PACG.
DOI: 10.1016/j.ophtha.2025.12.030
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