Treatment of Chronic Angle-Closure Glaucoma with ≥180° Iridotrabecular Contact of the Anterior Chamber Angle (PAC and PACG)

This protocol covers the management of patients with chronic angle-closure glaucoma presenting with ≥180 degrees of iridotrabecular contact of the anterior chamber angle, peripheral anterior synechiae, and/or elevated intraocular pressure — with or without glaucomatous optic neuropathy.

Clinical Scenario

Primary angle closure (PAC) is characterised by ≥180° iridotrabecular contact with peripheral anterior synechiae and/or elevated intraocular pressure, in the absence of glaucomatous optic neuropathy.

Primary angle-closure glaucoma (PACG) meets the same criteria for angle contact and IOP but additionally involves glaucomatous optic neuropathy. Both presentations require prompt intervention to prevent structural progression.

Approach to Treatment

Management in this scenario centres on a laser-based procedure designed to relieve the mechanism of angle closure. In certain cases, a surgical approach targeting the lens may be considered as an alternative initial strategy.

The complete treatment algorithm — including procedural selection criteria and individualised decision points — is available in the full protocol.

Treatment Goal

Successful intervention is confirmed by repeat gonioscopy demonstrating that the anterior chamber angle is open following the procedure.

Instant Access to Structured Evidence-Based Regimens

References

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
Laser peripheral iridotomy may be performed using a thermal (i.e., argon or diode) and/or Nd:YAG laser.
Lens extraction is an effective treatment for patients with PACG and PAC with markedly elevated IOP.
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.
Confirm by repeat gonioscopy that the angle is open after intervention.

DOI: 10.1016/j.ophtha.2025.12.030

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