Longitudinal Management of Primary Angle Closure Suspect

Tsai comments on the study of Yuan et al who designed and implemented a landmark population-based study to better elucidate baseline predictive factors that assist clinicians in individualizing management in patients with a diagnosis of primary angle closure suspect (PACS). As a clinician evaluating and managing a patient with bilateral asymptomatic PACS, it is comforting to know that the likelihood of that patient developing PAC or primary angleclosure glaucoma (PACG) is rather low based on the results of the large randomized clinical trials described here. In deciding whether to recommend prophylactic laser peripheral iridotomy (LPI) or close observation in an asymptomatic patient with PACS, the ZAP trial results indicate that the clinician can make this clinical determination based on n intraocular pressure (IOP), central anterior chamber depth (ACD), and limbal ACD without the need for more sophisticated AS-OCT measurements. In addition to the comprehensive ocular examination (including dynamic gonioscopy), patient factors such as age, sex, race, ethnicity, and refractive status should be considered since risk factors for the development of PACG include older age, Asian race, female sex, hyperopia, and positive family history. The 14-year longitudinal results in this study using data from the ZAP trial suggest that clinicians can rely on traditional methods of clinical evaluation in determining whether prophylactic LPI is the ideal management recommendation for individual patients with asymptomatic PACS. The cumulative risk of conversion to PAC appears to be relatively low in a community-based population with asymptomatic PACS. Therefore, in patients who might not benefit greatly from prophylactic LPI close observational management may be a reasonable alternative to laser therapy.