In chronic NAG a filtration surgery, like trabeculectomy, may become indispensable when either medication fail to control progression of disease or when patient is not ready to continue the treatment.
It is absolutely necessary to establish true state of angle of AC before embarking on trabeculectomy in chronic congestive glaucoma because if trabeculectomy is performed in an eye with more than half of the functioning angle of anterior chamber, the result may be persistent flat AC and danger of loss of the eye. A good gonioscopy may be instrumental in deciding to go for peripheral iridotomy/iridectomy or trabeculectomy.
Well said , In such cases trabeculectomy with peripheral iridectomy is best option.
Classify the angle closure as per ISGEO Classification as PACS, PAC or PACG.
Go ahead with laser iridotomy (LI) for the eye with occludable angles; evaluate the fellow eye and if need be do a LI.
If IOP isn't controlled post LI, rule out Plateau iris by UBM/ASOCT.
If IOP doesn't come down to desired level, post LPI add topical medications as you would do for a POAG case.
If despite anti glaucoma medications (post LI), target IOP is not attained, then plan a filtering surgery.
Watch out for Malignant Glaucoma post filtering surgery in cases with severe damage. Get a HVF 10-2 done to rule out split fixation in advanced cases.
Use releasable sutures, avoid immediate post shallow AC.
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