Elsevier

Ophthalmology

Volume 110, Issue 10, October 2003, Pages 1869-1879
Ophthalmology

Regular article
Interventions for angle-closure glaucoma: An evidence-based update

https://doi.org/10.1016/S0161-6420(03)00540-2Get rights and content

Abstract

Purpose

To assess the interventions to treat acute angle closure (AAC) and primary angle closure (PAC) with or without glaucomatous optic neuropathy.

Clinical relevance

Primary angle closure is one of the leading causes of blindness in East Asia. At present, there are few clinical guidelines on the optimal treatment of AAC or PAC in the affected or contralateral eye.

Methods

All randomized clinical trials, prospective controlled clinical trials, nonprospective controlled clinical trials, and retrospective case series with >50 cases that evaluated treatments for AAC or PAC were included. Studies published in the English language were identified from MEDLINE, PubMed, EMBASE, and the Cochrane Collaborations, as well as by a hand search of the reference lists of important articles.

Results

Nine randomized clinical trials and 24 nonrandomized clinical trials and large case series were evaluated. Laser peripheral iridotomy (LPI) has been found to be as effective as surgical peripheral iridectomy in randomized clinical trials of the affected and contralateral eyes of AAC or PAC patients with or without evidence of glaucoma. In another randomized clinical trial, latanoprost was found to decrease intraocular pressure (IOP) more than timolol for PAC in patients for whom LPI alone failed.

Conclusions

This review suggests that LPI should be recommended for the treatment of affected and contralateral eyes of AAC patients. In patients with PAC and insufficient treatment with LPI, latanoprost eye drops may decrease IOP more than timolol. There is still insufficient evidence about other interventions for the treatment of AAC and PAC.

Section snippets

Search strategy for the identification of studies

A comprehensive search was conducted to identify all relevant randomized clinical trials, controlled clinical trials, prospective noncontrolled clinical trials, and retrospective cases series with >50 cases of AAC or PAC with or without GON reported with the primary objective of evaluating interventions for the treatment of AAC, AACG, PAC, or PACG. Reasons for study exclusion included case series with <50 reported cases and studies of glaucoma patients that included cases but did not report the

Summary of evidence

Nine randomized clinical trials assessed treatment techniques for all forms of angle closure (AAC/AACG, n = 3; PAC/PACG, n = 3; contralateral eye prophylaxis, n = 2; and mixed population, n = 1). Outcomes assessed included long-term control of IOP, changes in VA, visual field progression, and progression of peripheral anterior synechiae. Most studies were not masked, the sample sizes varied from 12 to 52 patients, and the follow-up time ranged from 3 weeks to 3 years. Two trials—by Goins et al11

Clinical recommendations

We have surveyed the findings of the literature of studies that evaluated interventions for AAC, PAC, and prophylactic treatment of the fellow eye in AAC patients. Few randomized clinical trials have been conducted in this field, and we therefore selected a mixture of epidemiologic study designs: randomized clinical trials, controlled clinical trials, and large retrospective case series (n > 50). The overall quality of the literature was poor. Only one of the nine randomized clinical trials

Conclusions

The literature is often difficult to interpret because mixed populations have been studied and because treatments are not necessarily equally effective for AAC and PAC. Researchers have frequently included a mixture of angle-closure types,11 and often only combined results are reported. Furthermore, the diagnostic criteria for including patients in studies of angle closure have not been standardized, and there is a need to establish a uniform classification, as previously proposed.9 It is

Questions for review and CME credit request

The American Academy of Ophthalmology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Academy designates this educational activity for a maximum of one hour in category 1 credit towards the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. Requests for CME credit must be made within one year of the date of

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    Manuscript no. 220530

    Supported by the Robert E. McCormick Scholar Award from Research to Prevent Blindness, New York, NY (DSF).

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