The angle of the eye is the “angle” between the cornea (the clear window of the eye) and the iris (the colored part of the eye) where fluid (aqueous) inside of the eye drains out to the trabecular meshwork or “sink.” Some people are born with narrow, draining angles. Some develop increasing narrowing of the angle with age. As we age, the lens of the eye grows in circumference by adding rings like a tree. In people with narrow angles, this increase in circumference encroaches on the already limited anterior segment space. If left untreated, further narrowing of the angle can causes the pressure to build up and increase the risk of an acute attack of Narrow or Closed Angle Glaucoma which can cause sudden pain and blindness. Many patients with narrow angles will ultimately develop angle closure. Narrow angle can cause glaucoma (permanent optic nerve damage with vision loss) and causes almost half of the blindness from glaucoma.
There are 3 options to treat Narrow Angles:
1. Observation: if the narrow angle is minimal or is not causing any symptoms (occasional headache, brow ache, blurry vision), the angle can we watched periodically with gonioscopy (a contact lens with 4 mirrors). There, however, is a risk of sudden loss of vision and angle closure. Most eye surgeons recommend laser iridotomy or lens removal soon to avoid this uncertain risk. Either way, be sure to return for repeat gonioscopy and tell your eye surgeon of headaches, brow aches, or vision changes, especially in the evening or after dilation (after dilation starts to wear off.)
2. Laser Iridotomy: we use a laser to make a hole in the colored iris to help open the angle. Laser iridotomy helps prevent angle closure. It can also delay the need for lens removal if the lens is not interfering with vision or does not have a significant cataract. It does not prevent the increasing lens size from causing encroachment on the anterior chamber angle, and it has its own set of complications, including transient intraocular pressure rise, inflammation (iridocyclitis), hyphema, further cataract formation, endothelial cell loss, and synechia formation. A laser iridotomy is usually done on each eye during the same visit to avoid the risk of angle closure to the other eye. It usually takes a few minutes per eye. We give a topical anesthetic to help with discomfort. Steroid drops are given four times a day for 2-3 days after the procedure to help decrease inflammation. Rarely, the laser iridotomy needs to be repeated if the original laser hole closes. If the angle continues to narrow despite the laser iridotomy, lens removal is recommended.
3. Lens removal: this removes the lens that is growing. This offers the advantage of improving the patient’s uncorrected vision and preventing further maturation of the lens (developing a hard cataract). Lens removal or cataract surgery decreases the risk of angle closure essentially to zero. The lens never grows back. This procedure has its own risks which can be further discussed with your eye surgeon. Lens removal is the best way to remove the risk of angle closure in most patients.
If Patient chooses Observation: Please sign below stating risks, alternatives, and the increased risk of angle closure were discussed and are understood.