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    Techniques for treating narrow angle glaucoma

    Clinicians have a variety of tools at their disposal to treat narrow angle glaucoma, according to Sunita Radhakrishnan, MD, who provide an overview of these possibilities during the Glaucoma Symposium CME at the 2016 Glaucoma 360 meeting.

    To diagnose primary angle closure, the American Academy of Ophthalmology’s (AAO) Preferred Practice Pattern recommends looking for contact between the iris and the anterior chamber angle at the posterior trabecular meshwork or an anterior structure.

    In early stages, clinicians should see 180º of iridotrabecular contact, but the eye is otherwise normal, said Dr. Radhakrishnan, who is with of the Glaucoma Center of San Francisco. In the next stage, physicians should see elevated intraocular pressure (IOP) or peripheral anterior synechiae (PAS). This stage is termed primary angle closure.

    More G360: MIGS making big difference in glaucoma management

    But clinicians should only use the term “glaucoma” when they also see glaucomatous optic neuropathy, she said. Dr. Radhakrishnan pointed out that acute angle closure crisis may or may not lead to glaucoma. 

    ‘Look for it’

    Noting that clinicians “won’t see it until you look for it,” Dr. Radhakrishnan recommended looking for angle closure with gonioscopy in every patient. She recommended periodic gonioscopy in phakic patients, even those with open angles in the first assessment.

    “With time and with the development of cataracts, some of these patients will develop angle closure that requires intervention,” Dr. Radhakrishnan said. “So it’s important to monitor them.”

    More: Tracking glaucoma progression with precision medicine

    This approach provides direct visualization of the angle structures, is quick and inexpensive, and affords 360º evaluation of the angle width, she said.

    As treatment, the AAO Preferred Practice Pattern recommends considering iridotomy in primary angle closure (PAC), in acute angle closure crisis (AACC), in the fellow eye in an AACC, and in primary angle-closure glaucoma (PACG). The AAO guidelines say it “may be considered” in the case of and PAC suspect.

    Factors to be considered include the extent of angle closure, the refractive error, the anterior chamber depth and lens position, the use of ocular or systemic medications that may provoke papillary block, and difficulty in accessing eye care.

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