Updated PPP for Angle-closure Disease Stresses Gonioscopy, Imaging-based Monitoring

The new PPP for PACD details the proper technique for performing dark-room dynamic gonioscopy, which the AAO posits is crucial to diagnose PACD, preferably in conjunction with ultrasound biomicroscopy and anterior segment OCT. Click image to enlarge. Earlier this week, we published two news stories summarizing the recent updates to the Preferred Practice Patterns (PPPs) for primary open-angle glaucoma (POAG) and POAG suspects put forth by the American Academy of Ophthalmology (AAO). In addition to these, the AAO also revised its PPP for primary angle-closure disease (PACD). Below, we’ll discuss how these guidelines have shifted from 2021. Details on the updates were elicited by using ChatGPT to compare the 2021 and 2026 documents, which were then edited for clarity and clinical significance, and enhanced with feedback from Dr. Rixon. Risk FactorsMuch like the revised PPPs for POAG and POAG suspects, the list of established risk factors for PACD now incorporates more imaging-derived and biometric parameters, including shorter axial length, smaller corneal diameter, reduced angle width, decreased anterior chamber depth and increased lens thickness. The document also de-emphasizes steep corneal curvature and anterior lens position, which were previously included among PACD risk factors in 2021. Family history is also given more prominence.Andrew Rixon, OD, of the Memphis VA Medical Center, believes that these updates were necessary to capture a more well-rounded clinical picture of each patient. “Imaging of the anterior segment and biometric measurements, as well as the dynamics of the individual anterior segment, need to be incorporated in risk stratification and decisions to intervene or monitor,” he says.Diagnosis and TestingThe 2026 PPP features a more detailed discussion on the importance of gonioscopy and guides clinicians through the specific techniques required to properly perform this vital, yet underused, test. In the document, the AAO states, “Dark-room dynamic gonioscopy should be performed to diagnose PACD and to verify improvement in angle configuration following treatment.” According to Dr. Rixon, “Explicit instruction of the ‘how-to’ of gonioscopy is a must-read.” He explains, “Not only is gonioscopy underutilized, but it may not be universally performed in a method that provides the most sensitive assessment of the irido-trabecular relationship. The beam needs to be small enough that it doesn’t unintentionally reduce the pupil size and change how the peripheral iris interacts with the angle.” The AAO, as well as Dr. Rixon, also emphasize that gonioscopy should be performed on a regular basis when monitoring and treating these patients, including after intervention to ensure the angle is open.The AAO also now recommends that ultrasound biomicroscopy and anterior segment OCT “can complement gonioscopy and aid in the diagnosis of angle closure,” while noting that the former modality is superior at identifying plateau iris. The new PPP cites a longitudinal study showing that iridotrabecular contact on AS-OCT—even when graded as “open” on gonioscopy—may predict future angle closure. Since both AS-OCT and gonioscopy provide complementary information, Dr. Rixon reiterates that “practitioners should combine those vantage points to assess the individual's anatomical characteristics to determine management.”The document also now includes guidance to assess corneal endothelial health with specular/confocal microscopy, given that acute angle-closure crisis and angle-closure glaucoma can reduce endothelial cell density/morphology.ManagementThe 2026 PPP relays more recent data from several trials on monitoring vs. LPI for angle-closure suspects but keeps a cautious stance. The cited studies show that while prophylactic LPI reduces the risk of angle closure—and appears to be cost-effective—absolute progression is still low. “A patient-centered conversation revolving around the person’s individual risks, risk tolerance and circumstances must be had prior to performing an LPI,” notes Dr. Rixon, who also points out that “it’s difficult to apply large studies exactly to the individual patient.”Newer data have also shifted the AAO’s recommendations for the management of primary angle-closure and primary angle-closure glaucoma (PACG), which now emphasize the effectiveness of early lens extraction for these patients with markedly elevated IOP. The EAGLE trial found that this intervention produced better IOP control and quality-of-life than LPI; specifically, at three years, those who underwent lens extraction were 10 times more likely to remain controlled without medications. “Early lens extraction remains a fantastic option and should always warrant consideration,” Dr. Rixon says. “ODs need to have meaningful conversations with the surgeons they are working with to determine how this is employed, as the quality of life benefits and burden reduction are significant.” The new PPP also reflects an increasing trend toward goniosynechiolysis and phaco-goniotomy for advanced PACG cases. As ODs, Dr. Rixon asserts, “We need to be aware of these techniques and the postoperative management responsibilities.”Treatment protocols for acute angle-closure crisis are comparable to those stated in 2021 (medical IOP reduction, then LPI/iridectomy when feasible). The AAO restates the importance of evaluating the fellow eye and considering prophylactic LPI, “since approximately half of fellow eyes of acute angle-closure patients can develop an acute angle-closure crisis within five years.”Zonular damage was added to the list of potential complications of LPI, and the new guidelines state that most new-onset dysphotopsias after the procedure are transient and resolve by six months. As far as perioperative responsibilities, the AAO places new emphasis on ensuring true patency by visualizing flow/pigment and checking IOP within 30 minutes to two hours postoperatively. Dr. Rixon agrees with this recommendation, noting that it “underscores that having an LPI and having an LPI that results in patency are not the same thing.”Follow-upRevised follow-up guidelines advise clinicians to perform serial dark-room gonioscopy to track peripheral anterior synechiae and secondary closure from lens changes after LPI, as well as incorporate baseline and follow-up RNFL/macular ganglion cell imaging and perimetry to monitor for glaucomatous progression. As Dr. Rixon explains, “Serial dark room gonioscopy is still required to understand first whether there was angle widening and second whether additional mechanisms are at play that may ultimately create angle closure.” Postoperative recommendations also now include mental health counseling.TakeawaysOverall, while core definitions and first-line strategies remain stable, the updates in the 2026 PPP for angle-closure disease reflect newer data from randomized trials and systematic reviews that emphasize the potential value of early lens extraction, the importance of properly performed gonioscopy and the need for image-based longitudinal monitoring.Click here for the journal source. Gedde SJ, Chopra V, Vinod K, et al. Primary angle-closure disease preferred practice pattern. Ophthalmology. February 9, 2026. [Epub ahead of print].  This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.