Plateau Iris Glaucoma Treatment & Management

Updated: May 06, 2016
  • Author: Jim C Wang (王崇安), MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

Surgical management is the primary treatment modality in patients with plateau iris configuration or syndrome. However, pilocarpine may produce iris thinning and facilitate angle opening in some cases.

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Surgical Care

Because some degree of pupillary block frequently exists in patients with plateau iris configuration, peripheral laser iridotomy always should be performed as the first intervention in all patients suspected of having plateau iris.

A patent iridotomy may be therapeutic in reducing risks of angle closure. However, in some patients, laser iridotomy may not significantly alter the anterior chamber depth or anatomy. Even after a successful iridotomy produces what appears to be a well-opened angle, periodic gonioscopy remains crucial because these patients may have incomplete plateau iris syndrome or the angle may narrow further with age because of the enlargement of the lens. Although usually recognized in the postiridotomy period, plateau iris syndrome may develop years later. Patients with plateau iris configuration should not be assumed to be cured, even though plateau iris syndrome does not develop immediately.

Images before and after laser iridotomy are shown below.

Ultrasound biomicroscopy, plateau iris syndrome. ( Ultrasound biomicroscopy, plateau iris syndrome. (A) Appositional anterior chamber angle in dark condition prior to laser iridotomy. (B) After laser iridotomy, the angle remains occludable. (C) After peripheral laser iridoplasty, the peripheral iris is thinned, opening the angle and significantly reducing the risk of closure.

Peripheral laser iridoplasty

If persistent iridotrabecular apposition is present despite a patent iridotomy, the diagnosis is consistent with plateau iris syndrome, and peripheral laser iridoplasty is indicated.

Argon laser peripheral iridoplasty (ALPI) is the procedure of choice to effectively open an angle that remains occluded after successful laser iridotomy. The procedure consists of placing laser burns on the surface of the peripheral iris to contract the iris stroma between the site of the burn and the angle. Peripheral location of long-duration, low-power, large spot size laser burns is essential for success. The result is iris stromal tissue contraction and compaction that physically widens the angle and prevents the apposition of the peripheral iris against the trabecular meshwork. [14] More recent optic coherence tomography studies suggest that thinning of the iris after ALPI also contributes to opening of the angle. [15]

ALPI is highly effective, and the effect is maintained for years. However, even after successful opening of the angle, regular gonioscopic examination remains crucial. A small proportion of patients may develop reclosure of the angle, which is readily reopened with repeat ALPI. Urrets-Zavalia syndrome (prolonged mydriasis unresponsive to pilocarpine) is an uncommon complication of ALPI that typically resolves spontaneously within 1 year. [16]

Other surgical intervention

If angle closure persists despite iridotomy and sufficient peripheral laser iridoplasty, surgical intervention in the form of lens extraction, endoscopic laser cycloplasty, goniosynechialysis, trabeculectomy, or tube-shunt implantation surgery may be needed to open the anterior chamber angle, allow bypass of aqueous flow, and control IOP. [17, 18]

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Consultations

Consultation and/or comanagement with a glaucoma specialist may be helpful in patients who fail to respond to laser iridotomy and iridoplasty.

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