A 60-year-old hyperopic woman (+4.00) attends for a routine glasses prescription. She has no eye symptoms at all — no haloes, no headaches, no episodes of blurred vision. As part of the examination the optometrist performs gonioscopy and finds very narrow angles, referring her ‘before anything happens’. Her pressures are 18 mmHg both eyes.
Examination Findings
Visual acuity 6/6 each eye with correction. Pressures: 18 mmHg both eyes. Anterior chambers shallow with a convex iris profile. Gonioscopy: appositional closure of the trabecular meshwork in three quadrants both eyes, but no peripheral anterior synechiae — the iris touches the drain but has not stuck to it. Pupils react normally. Optic discs: cup 0.3, healthy rims. Fields full.
Investigations
Gonioscopy is the definitive test and is repeated after treatment. Baseline disc imaging and fields are recorded so any future damage is detectable. Anterior segment OCT can document the angle anatomy where available.
Questions to Think About
- Why treat an eye with normal pressure and no damage?
- What does the absence of synechiae change?
- Why are both eyes treated on the same reasoning?
Diagnosis
Primary angle-closure suspect, bilateral — occludable angles without synechiae, normal pressure, no glaucomatous damage.
Reasoning
Reasoning: This woman is a primary angle-closure suspect: the anatomy for an attack (or for silent chronic closure) is present, but no closure has become permanent yet — there are no synechiae, the pressure is normal and the nerve is healthy. The absence of synechiae is exactly why treatment works so well now: a laser peripheral iridotomy removes the pupillary-block component while the angle can still fully reopen. Waiting for an attack or for damage would waste that window. Diagnosis: primary angle-closure suspect, both eyes. Management: typical management includes prophylactic laser peripheral iridotomy to both eyes, with repeat gonioscopy afterwards to confirm the angle has opened; if significant closure persists despite a patent iridotomy, plateau iris configuration is considered and lens extraction discussed. She is counselled that the laser is preventive, quick, and done before any damage — and warned that dilating drops are only used under supervision until the angles are secured.
Differential Diagnosis
- Plateau iris configuration — considered if the angle stays closed after a patent iridotomy; not diagnosed yet.
- Chronic angle closure — ruled out: no synechiae, normal pressure, healthy nerves.
- Primary open-angle glaucoma — ruled out: angles are narrow, not open.
Management
Typical management includes laser peripheral iridotomy to both eyes as a preventive measure, followed by repeat gonioscopy to verify opening. If appositional closure persists with a patent iridotomy, plateau iris is investigated and options including lens extraction are discussed. Long-term follow-up of pressure, angles and discs continues, since a small proportion still develop pressure rises. The patient is advised to seek urgent care for any future episode of haloes, headache or blurred vision.
Key Learning Points
- A ‘suspect’ is treated, not just watched: iridotomy prevents both acute attacks and silent chronic closure.
- No synechiae means the angle can still fully reopen — the ideal moment for laser.
- Both eyes share the anatomy, so both eyes are secured.
- Gonioscopy, not pressure, makes this diagnosis — the pressure is normal until it suddenly is not.
Red Flags
- Occludable angles in a hyperopic older woman — the classic at-risk profile; do not leave unsecured.
- Dilating drops in an unsecured narrow angle — only with a plan and supervision.
- Angle closure that persists after iridotomy — think plateau iris, not treatment failure.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.