First-line therapy in angle-closure glaucoma varies with patients

Should the initial treatment in angle-closure glaucoma be laser, lens removal, or trabeculectomy? The answer depends on thepatient, said Clement C.Y. Tham, Department of Ophthalmology and Visual Sciences, Chinese University of Hong Kong.

"There's no single answer," Dr. Tham said. "Drug therapy and other procedures must be considered, too."

For example, in asymptomatic, angle-closure glaucoma, the first therapy should be to try to re-open all appositionally closedportions of the angle, according to Dr. Tham. For this, his treatment of choice is laser peripheral iridotomy.

"Laser peripheral iridotomy is the first-line intervention in most, if not all, cases of angle-closure glaucoma," Dr. Thamsaid. "However, this may not be useful if total/subtotal peripheral anterior synechiae are present, or if the mechanism ofangle-closing is something other than pupilary block."

Laser peripheral iridoplasty should be considered in patients with elevated IOP and persistent appositional angle closureafter iridotomy, he said. Lens extraction should be reserved for patients who already have cataracts or presbyopia, he added.

Four possible scenarios exist for patents with primary angle-closure glaucoma and in whom drugs are needed to controlIOP:

• For patients who have a co-existing cataract and whose IOP is controlled with drug therapy, consider phacoemulsificationalone.
• For patients who have a co-existing cataract and whose IOP is uncontrolled by drugs therapy, consider a combination ofphacoemulsification and trabeculectomy.
• For patients whose IOP is controlled by drugs and no cataract, there are no relevant data to suggest surgicalintervention is necessary.
• For patients who have no cataract but IOP that's not controlled by drug therapy, there are insufficient patient numbersto draw hard and fast conclusions, but phacoemulsification may be considered if such patients are already presbyopic, Dr.Tham suggested.