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    Techniques for treating narrow angle glaucoma

     

    Discuss with patients 

    If iridotomy is not done, clinicians should discuss with patients the symptoms of an acute angle closure crisis and which medications to avoid.

    There is no way to predict which PAC suspect patients will have an acute attack, said Dr. Radhakrishnan. While these attacks are not common, they can be devastating. On the other hand, the relative risk of laser iridotomy is low. So it’s important to involve the patient in the treatment decision, she added.

    In an iridotomy, the elimination of the papillary block results in a flat iris profile. The goal of the treatment is to reverse the iridotrabecular contact, control the IOP, and prevent or reduce damage to the optic nerve.

    More: Glaucoma ‘tsunami’ bearing down on how EyeMDs will practice medicine

    Its efficacy depends on the stage of the disease, and the mechanism of angle closure, said Dr. Radhakrishnan. She pointed out that laser peripheral iridotomy eliminates only the papillary block.

    While most patients who are a PAC suspect don’t need any further intervention, clinicians should continue to monitor them after laser peripheral iridotomy. Up to a third have residual angle closure due to a non-pupillary block.

    When patients have elevated IOP after laser peripheral iridotomy, a range of additional treatments may be considered, said Dr. Radhakrishnan. She listed medications, laser trabeculoplasty, iridoplasty, clear lens extraction, cataract surgery, glaucoma surgery, and combined cataract and glaucoma surgery as options.

    Phaco influence on glaucoma

    Phacoemulsification alone achieves a 13% reduction in IOP in primary open-angle glaucoma, 20% in exfoliative glaucoma, 30% in primary angle-closure glaucoma and 71% in an acute angle closure crisis, she said. The reduction in need for glaucoma medication follows a similar pattern.

    Related: Managing functional visual field loss with low IOP

    Because of these results, clear lens extraction in primary angle closure is under study with the EAGLE trial in the United Kingdom and East Asia.

    However, Dr. Radhakrishnan counseled caution to performing phacoemulsion in patients with advanced optic nerve damage, or who are already receiving maximum tolerated medical treatment, and in those patients with small eyes.

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