If acute angle closure is present:
- Treat medically. See 9.4, ACUTE ANGLE CLOSURE GLAUCOMA.
- A laser PI is performed within 1 to 3 days if the angle closure attack can be broken medically. If the attack cannot be controlled, a laser or surgical PI may need to be done as an emergency procedure. Consider a laser iridoplasty to break an acute attack not responsive to medical treatment and PI.
- One week after the laser PI, gonioscopy should be repeated prior to dilating the eye with a weak mydriatic (e.g., tropicamide 0.5%). If the IOP increases or a spontaneous angle closure episode occurs, plateau iris syndrome is diagnosed and should be treated with an iridoplasty. Second-line therapy includes chronic instillation of a weak miotic agent (e.g., pilocarpine 0.5% to 1% t.i.d. to q.i.d.).
- If the patients IOP does respond to a laser PI (e.g., plateau iris configuration), then a prophylactic laser PI may be indicated in the contralateral eye within 1 to 2 weeks.
If acute angle closure is not present:
- Laser PI to relieve any pupillary block component; also done to prove pupillary block is not the primary mechanism.
- Check gonioscopy every 4 to 6 months to evaluate the angle.
- Most do well with close observation alone. Perform iridoplasty if new PAS or further narrowing of the angle develops.
- If the angle continues to develop new PAS or becomes narrower despite iridoplasty, then consider lens extraction. Can consider ECP at the time of phacoemulsification to shrink ciliary processes. If uncontrolled IOP, treat as CACG (see 9.5, CHRONIC ANGLE CLOSURE GLAUCOMA).