This protocol addresses the management of patients with primary angle closure (PAC) or primary angle-closure glaucoma (PACG) in whom initial laser or surgical intervention has been performed, yet gonioscopy confirms that the angle has not adequately opened — with ≥180 degrees of iridotrabecular contact persisting.

Why Escalation Is Required

The prior step involved laser peripheral iridotomy — using a thermal (argon or diode) and/or Nd:YAG laser — or, alternatively, earlier lens extraction (phacoemulsification/clear lens extraction). The key goal of that intervention was confirmation by repeat gonioscopy that the angle is open. That goal was not met: significant iridotrabecular contact remains, necessitating the next management step.

Clinical Scenario

The patient has ≥180 degrees of iridotrabecular contact of the anterior chamber angle, accompanied by peripheral anterior synechiae (PAS) and/or elevated intraocular pressure. The specific designation depends on whether glaucomatous optic neuropathy is present: primary angle-closure glaucoma (PACG) when optic neuropathy is confirmed, or primary angle closure (PAC) when it is not.

Treatment Approach (Partial)

Management at this stage centres on chronic ocular pressure-lowering therapy or a surgical intervention. The appropriate path — and any role for additional laser procedures — depends on the individual anatomy remaining after prior treatment. The full decision pathway is in the structured protocol.

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
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.

DOI: 10.1016/j.ophtha.2025.12.030

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What to Do When Laser Peripheral Iridotomy Did Not Open the Angle in Chronic Angle-Closure Glaucoma

Why Escalation Is Required

Clinical Scenario

Treatment Approach (Partial)

References