Exploring Alternatives to LPI for Angle Closure Glaucoma

One study found that 80% of patients with at least 1 narrow angle eventually developed some form of angle closure after undergoing LPI. | Image credit: wasan - stock.adobe.com

Traditional approaches to managing angle closure glaucoma, including weighing the usefulness of laser peripheral iridotomy (LPI) against phacoemulsification, need to be challenged to propel care forward, according to Bobby Saenz II, OD, MD, FAAO, a clinical assistant professor at the Rosenberg School of Optometry at the University of the Incarnate Ward, during a presentation at Southeastern Congress of Optometry (SECO) 2025.¹

Saenz’s discussion, entitled “Ocular Disease Myths Shattered,” covered a range of topics, beginning with clarifying the 3 groups of patients with narrowing of the drainage angle in the eye: patients suspected of having primary angle closure, patients with primary angle closure, and patients with chronic angle closure with damage. He emphasized the importance of diagnosing asymptomatic cases, as most patients with the condition do not present with symptoms.

While the American Academy of Ophthalmology recommends LPI for all patients with angle closure, Saenz questioned its effectiveness, citing a meta-analysis that found insufficient evidence supporting LPI in slowing progressive visual field loss.² Additionally, 80% of patients with at least 1 narrow angle eventually developed some form of angle closure after undergoing LPI, further complicating whether the procedure has value as a preventive tool.³

"It's not always easy or so straightforward [to consider options outside of LPI], but we should be considering them more." — Bobby Saenz II, OD, MD, FAAO

Alternatively, iridotomy could reduce patients' risk of developing angle closure by 50%, according to data from the ZAP study (ISRCTN45213099), which tracked 900 eyes with narrow angles over 6 years.⁴ However, the study concluded that widespread prophylactic LPI for angle closure suspects was not recommended. Saenz shared his experience presenting the study at a conference, where it was met with skepticism, highlighting the ongoing controversy surrounding LPI and the need for better treatment options.

“I always try to go through the literature with [patients]. Am I going to be able to convince everybody? No. Will some surgeons vehemently disagree with me? Absolutely, yes. Am I going against the American Academy of Ophthalmology practice pattern guideline? Absolutely. But I think looking at the literature, [these other options] are something we have to consider.”

Considering phacoemulsification as an alternative treatment, Saenz discussed the EAGLE study (ISRCTN44464607), which demonstrated that patients with angle closure were more likely to maintain good intraocular pressure (IOP) control with phacoemulsification compared with LPI.⁵ Financial and insurance coverage considerations were also addressed, as phacoemulsification can be a more expensive procedure.

Shifting focus, Saenz presented a case of non-arteritic ischemic optic neuropathy in a 63-year-old African American female with unilateral disc edema and subretinal fluid. The discussion covered the importance of recognizing common causes of disc edema, prompt diagnosis, and the use of magnetic resonance imaging and blood tests to confirm and monitor the condition.

Corneal edema was another topic of discussion, with Saenz exploring its causes, such as epithelial defects, interstitial keratitis, and endothelial dysfunction, including Fuchs dystrophy. He emphasized the role of steroids in upregulating endothelial pumps to treat corneal edema and discussed anterior stromal puncture as a treatment for recurrent corneal erosions. He also shared his personal experience with recurrent corneal erosions and the effectiveness of corneal wiping to improve adhesion.

Saenz then addressed complications associated with posterior laser procedures, particularly aqueous misdirection, which can lead to angle closure and high IOP. He discussed treatment options, including creating laser channels behind the intraocular lens and performing vitrectomy, stressing the importance of recognizing and managing these complications effectively.

The session concluded with Saenz underscoring the critical role of optometrists in managing complex cases, advocating for continuous learning, and the application of the latest research in clinical practice.

“This isn't black and white. It's not like [phacoemulsification] all the time or that there's not going to be any more iridotomies. I just think that maybe there should be a lot less iridotomies as we're dealing with these patients who have narrow angles, who are in angle closure, and these patients who have angle closure glaucoma. We should be considering a lens-based procedure for all these patients. It's not always easy or so straightforward, but we should be considering it more.”

References

1. Saenz R. Ocular disease myths shattered. Presented at: SECO 2025; February 26-March 2, 2025; Atlanta, Georgia.

2. Le JT, Rouse B, Gazzard G. Iridotomy to slow progression of visual field loss in angle‐closure glaucoma. Cochrane Database Syst Rev. 2018;2018(6):CD012270. doi:10.1002/14651858.CD012270.pub2

3. Atalay E, Nongpiur ME, Baskaran M, Sharma S, Perera SA, Aung T. Biometric factors associated with acute primary angle closure: comparison of the affected and fellow eye. Invest Ophthalmol Vis Sci. 2016;57(13):5320-5325. https://pubmed.ncbi.nlm.nih.gov/27727395/

4. He M, Jiang Y, Huang S, et al. Laser peripheral iridotomy for the prevention of angle closure: a single-center, randomised controlled trial. Lancet. 2019;393(10181):1609-1619. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32607-2/abstract

5. Azuara-Blanco A, Burr J, Ramsay C, et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016;388(10052):1389-1397. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30956-4/fulltext