Peripheral Anterior Synechia Treatment & Management
- Author: Baseer U Khan, MD; Chief Editor: Hampton Roy, Sr, MD more...
No specific medical management exists pertaining to the treatment of peripheral anterior synechiae (PAS). In general, the treatment of the underlying etiology prevents the formation of peripheral anterior synechiae.
- The appropriate management of peripheral anterior synechiae depends on the disease process that leads to peripheral anterior synechiae formation. The following drug categories may be considered depending on the primary diagnosis: topical beta-blockers, topical alpha-agonists, topical carbonic anhydrase inhibitors, oral carbonic anhydrase inhibitors, topical prostaglandin analogs, miotics, cycloplegics, and topical corticosteroids.
- Treat intraocular pressure (IOP) as necessary.
- Topical alpha-agonists, beta-blockers, carbonic anhydrase inhibitors, and prostaglandin analogs may be useful in lowering intraocular pressure in eyes with peripheral anterior synechiae.
- Miotics are useful in pupil block due to primary angle closure but may accentuate angle closure in posterior pushing mechanisms.
- Miotics or prostaglandin analogs likely will not be useful in cases where 360° peripheral anterior synechiae exist.
- Inflammatory states
- Topical steroids minimize inflammation and, therefore, peripheral anterior synechiae formation.
- Cycloplegics should be used to prevent posterior synechiae.
- Miotics and epinephrine should be avoided because they can increase inflammation.
General principles in the surgical treatment of peripheral anterior synechiae are as follows:
- If peripheral anterior synechiae are to be successfully surgically treated to increase aqueous outflow, treatment should be undertaken within the first 612 months of formation according to conventional thinking. After this time, significant scarring has occurred in the trabecular meshwork and synechialysis will open the angle, but the trabecular meshwork will not be able to function normally. However, there has been more recent literature to suggest that peripheral anterior synechiae from an appositional etiology may be amenable to treatment even a few years after formation.
- The intraocular pressure of the contralateral eye will play a role in modifying the threshold for these procedures, ie, if the intraocular pressure is elevated or on the high end of normal, this would lower the threshold because it suggests poor baseline function of the exposed trabecular meshwork. The converse also would be true; with a low intraocular pressure, the threshold would be increased.
- Anterior chamber compression with Zeiss gonioprism may be successful, although unlikely, in breaking pupil block or early posterior synechiae.
- Nd:YAG/argon laser iridotomy
- This treatment is indicated when angle-closure glaucoma is the identified etiology of peripheral anterior synechiae; consider even with nonelevated intraocular pressure.
- Prophylactic treatment of the other eye should be considered in angle-closure glaucoma.
- Second eye risk is 50% within 5 years without an iridotomy.
- Surgical iridectomy
- Prophylactic iridectomy is recommended in patients who receive anterior chamber intraocular lenses (IOLs) or who are aphakic.
- Surgical iridectomy is performed in cases where a laser iridotomy is indicated but unable to be performed.
- Argon laser peripheral iridoplasty
- When peripheral anterior synechiae continue to form after an iridotomy has been performed, laser iridoplasty is indicated. By creating burns in the peripheral iris causing contraction of the iris, the iris is pulled away from the trabecular meshwork.
- Argon laser peripheral iridoplasty also may be useful in preventing peripheral anterior synechiae formation in a persistent narrow angle after iridotomy.
- Argon laser peripheral iridoplasty is useful in posterior pushing mechanisms, such as plateau iris and nanophthalmos.
- Argon laser pupilloplasty is used to expand/enlarge pupil, which may break acute angle-closure attack and/or posterior synechiae.
- Nd:YAG peripheral synechialysis can be attempted in early synechial closure but may not be effective if the synechiae are firm. Laser synechialysis should be attempted before surgical goniosynechialysis.
- Surgical goniosynechialysis[5, 6, 7, 8]
- Surgical lysis of synechiae has been shown to be an effective surgical modality when the etiology of the peripheral anterior synechiae formation has been secondary to primary angle closure.
- Using a smooth-tipped irrigating cyclodialysis spatula, the iris can be separated from the TM, rupturing the peripheral anterior synechiae. This is not recommended unless there is 270° or more of synechial closure. This is performed under either direct or indirect visualization of the meshwork intraoperatively.
- More recently, goniosynechialysis has been described using intraocular microforceps.
- If significant glaucomatous cupping associated with visual field loss is present, a filtering operation would be performed in addition to goniosynechialysis.
- Concurrent lens extraction (independent of the presence of a cataract) is strongly recommended when performing goniosynechialysis as removal of the lens helps to further widen the angle, which facilitates intraoperative access as well as removing an etiologic contribution to angle closure.
- Glaucoma filtering procedures
- Trabeculectomy, while the criterion standard of glaucoma filtering procedure, has generally had lower success rates in angle closure patients in the case of primary angle closure with higher rates of choroidal effusions, aqueous misdirection, and flat anterior chambers. In secondary angle closures, the etiologic process further reduces the likelihood of success such as in neovascular glaucoma or iridocorneal endothelial (ICE) syndromes.
- Primary tube shunt surgery is certainly a consideration in primary angle closure patients, and is strongly advised for secondary etiologies.
- The Mini Express Shunt is a potential alternative to trabeculectomy as well, given its preclusion to an iridectomy and relatively controlled outflow. More research in this area is required to fully evaluate this technology in this context.
- Goniophotocoagulation/panretinal photocoagulation is used to treat neovascular glaucoma.
- Choroidal tap is used to treat choroidal effusions or hemorrhage.
A rheumatologic consultation should be considered in patients with a sterile uveitis of unknown origin.
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|Description of PAS||Associations||Possible Conditions|
|PAS to all levels but not to cornea No bridging usually present||Angle-closure glaucoma|
|PAS to all levels, sometimes to cornea|
Bridging may be present
|Posterior pushing mechanism, postoperatively shallow AC, or from iris bombé|
|PAS with new vessels, multiple sites||Neovascularization|
|PAS tent and form columns up to, but not on, the cornea||Iridocyclitis with keratic and trabecular precipitates|
|Small PAS to scleral spur||Post-argon laser trabeculoplasty (ALT)|
|Iris Pulled Forward||Iris Pushed Forward|
|Neovascular membrane ICE membrane Posterior polymorphous dystrophy Epithelial/fibrous ingrowth|
|Primary angle-closure glaucoma|
Posterior synechiae resulting in iris bombé
Pseudophakic or aphakic pupil block
|Flat anterior chamber||Plateau iris|
-Post-pan retinal photocoagulation (PRP) or cryotherapy
Ciliary block (malignant) glaucoma (aqueous misdirection)
Posterior segment tumors
-Choroidal melanoma or metastasis
Iris cyst or tumor
Ciliary body cyst, tumor, or effusion
Contracting retrolental tissue
-Retinopathy of prematurity
-Persistent hyperplastic primary vitreous (PHPV)
Postscleral bucking surgery
Anterior lens subluxation (ectopia lentis)
Lens intumescence (phacomorphic)
|Argon laser trabeculoplasty|