Angle-closure glaucoma
ICD-10 H40.2 · ICD-11 9C61.3

What to Do When Lens Extraction Did Not Adequately Widen the Angle or Lower IOP in Angle-Closure Glaucoma with ≥180° of Iridotrabecular Contact

This protocol covers the management step for patients with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) who show ≥180 degrees of iridotrabecular contact (ITC) on gonioscopy — with peripheral anterior synechiae (PAS) and/or elevated intraocular pressure — and in whom a prior surgical intervention has not achieved the target outcomes.

Clinical scenario

Gonioscopy reveals at least 180° of ITC. Peripheral anterior synechiae (PAS) may be present, intraocular pressure may be elevated, or both findings coexist. In PAC, glaucomatous optic neuropathy is absent; in PACG, structural optic nerve damage accompanies these angle findings.

Previous treatment — insufficient response

Prior step: Lens extraction (phacoemulsification), performed alone or combined with goniosynechiolysis.

Goals that were not met: Widening of the anterior chamber angle and lowering of intraocular pressure.

Because these targets were not reached, escalation to the next treatment step is indicated.

What this next-step protocol involves

The regimen at this stage centres on chronic topical ocular hypotensive therapy as one component of management, with further surgical and procedural options addressed individually based on anatomy and clinical response. The complete decision framework is in the full protocol.

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References

DOI: 10.1016/j.ophtha.2025.12.030

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

This includes chronic topical ocular hypotensive agents, incisional surgery, and, rarely, laser trabeculoplasty surgery if, in the judgment of the treating ophthalmologist, sufficiently open trabecular meshwork exists following LPI to expect a reasonable IOP reduction.

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