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Study flow diagram.

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Figure 1

Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Forest plot of mean difference in intraocular pressure between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Figure 3

Forest plot of mean difference in intraocular pressure between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Forest plot of mean difference in angle width between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Figure 4

Forest plot of mean difference in angle width between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Forest plot of risk ratio of peripheral anterior synechiae between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Figure 5

Forest plot of risk ratio of peripheral anterior synechiae between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Forest plot of mean difference in best‐corrected visual acuity between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Figure 6

Forest plot of mean difference in best‐corrected visual acuity between iridotomy and no treatment at 1 and 5 years of follow‐up.

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Forest plot of risk ratio of adverse events (intraocular pressure spike and acute angle closure) between iridotomy and no treatment.

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Figure 7

Forest plot of risk ratio of adverse events (intraocular pressure spike and acute angle closure) between iridotomy and no treatment.

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Comparison 1: Iridotomy versus no treatment, Outcome 1: Intraocular pressure

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Analysis 1.1

Comparison 1: Iridotomy versus no treatment, Outcome 1: Intraocular pressure

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Comparison 1: Iridotomy versus no treatment, Outcome 2: Gonioscopic findings: angle width

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Analysis 1.2

Comparison 1: Iridotomy versus no treatment, Outcome 2: Gonioscopic findings: angle width

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Comparison 1: Iridotomy versus no treatment, Outcome 3: Gonioscopic findings: presence of peripheral anterior synechiae

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Analysis 1.3

Comparison 1: Iridotomy versus no treatment, Outcome 3: Gonioscopic findings: presence of peripheral anterior synechiae

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Comparison 1: Iridotomy versus no treatment, Outcome 4: Need for additional surgery to control intraocular pressure

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Analysis 1.4

Comparison 1: Iridotomy versus no treatment, Outcome 4: Need for additional surgery to control intraocular pressure

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Comparison 1: Iridotomy versus no treatment, Outcome 5: Best‐corrected visual acuity

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Analysis 1.5

Comparison 1: Iridotomy versus no treatment, Outcome 5: Best‐corrected visual acuity

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Comparison 1: Iridotomy versus no treatment, Outcome 6: Adverse events

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Analysis 1.6

Comparison 1: Iridotomy versus no treatment, Outcome 6: Adverse events

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Summary of findings 1. Iridotomy compared to no iridotomy for people with primary angle‐closure suspect

Iridotomy compared to no iridotomy for people with primary angle‐closure suspect

Patient or population: people with primary angle‐closure suspect
Setting: hospital or outpatient
Intervention: iridotomy
Comparison: no iridotomy

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of eyes
(studies)

Certainty of the evidence
(GRADE)

Comments

No iridotomy

Iridotomy

Proportion of progressive visual field loss at 1 year

No data were available for this outcome.

‐

‐

 

Mean change in IOP

(mm Hg) at 1 year

The mean IOP across control groups from 14.11 to 14.81

The mean IOP in the intervention group was on average 0.04 higher (95% CI −0.17 to 0.24).

‐

2598 (2)

⊕⊕⊕⊝
MODERATE1

5 year (MD 0.12 mm Hg, 95% CI −0.11 to 0.35; 2 studies, 2016 eyes of 1008 participants)

Gonioscopic findings

Mean angle width (Shaffer grading scale**) at 1 year

The mean Shaffer grade across control groups from 2.53 to 4.53 

The mean Shaffer grade in the iridotomy group was on average 4.93 units greater (95% CI 4.73 to 5.12).

‐

2598 (2)

⊕⊕⊕⊝
MODERATE1

5 year (MD 5.07, 95% CI 4.78 to 5.36; 2 studies, 2016 eyes of 1008 participants)

Presence of PAS at 1 year

10 per 1000

6 per 1000

(3 to 15)

RR 0.62
(95% CI 0.25 to 1.54)

2896 (3)

⊕⊕⊝⊝

LOW1,2

5 year (RR 0.41, 95% CI 0.24 to 0.67; 2 studies, 2738 eyes of 1369 participants)

Need for additional surgery: proportion of participants who received additional surgery to control IOP within 1 year***

4 per 1000

2 per 1000

(0 to 22)

RR 0.50
(95% CI 0.05 to 5.50)

960 (1)

⊕⊕⊝⊝

LOW1,2

 

Medications: mean number of medications used to control IOP at 1 year

No data were available for this outcome.

‐

‐

 

Quality of life measures

No data were available for this outcome.

‐

‐

 

Adverse events

IOP spike (≥ 30 mm Hg) at 1‐hour postiridotomy

0 per 1000

4 per 1000

(0 to 38)
 

RR 13.70 (95% CI 0.73 to 230.42)

1778 (1)

⊕⊕⊝⊝
LOW1,2

Deaths (9) and other serious AEs (27, 8 eye‐specific) by 5 years (ANA‐LIS); localized hyphema (257 eyes), localized corneal burns (1) by 72 months (ZAP)

Acute angle closure

5 per 1000

2 per 1000

(0 to 6)

RR 0.29 (95% CI 0.07 to 1.20)

3006 (3)

⊕⊕⊝⊝
LOW1,2

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
**Measure is sum of Shaffer grading of all 4 quadrants (range 0 to 16, larger number indicates wider angle).

***Timing of additional surgery was unknown.

AE: adverse events;CI: confidence interval; IOP: intraocular pressure; MD: mean difference; PAS: peripheral anterior synechiae; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

1Downgraded by one level for risk of bias.
2Downgraded by one level for imprecision: confidence interval of the risk ratio between groups is wide.

Figuras y tablas -
Summary of findings 1. Iridotomy compared to no iridotomy for people with primary angle‐closure suspect
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Table 1. AAO summary of clinical findings defining angle‐closure diseases

Primary angle‐closure suspect (PACS)

Primary angle‐closure (PAC)

Primary angle‐closure glaucoma (PACG)

Iridotrabecular contact greater than or equal to 180°

X

X

X

Elevated intraocular pressure OR peripheral anterior synechiae

X

X

Optic nerve damage

X

AAO: American Academy of Ophthalmology
Figuras y tablas -
Table 1. AAO summary of clinical findings defining angle‐closure diseases
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Comparison 1. Iridotomy versus no treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Intraocular pressure Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1.1 1‐year follow‐up

2

2598

Mean Difference (IV, Fixed, 95% CI)

0.04 [‐0.17, 0.24]

1.1.2 5‐year follow‐up

2

2016

Mean Difference (IV, Fixed, 95% CI)

0.12 [‐0.11, 0.35]

1.2 Gonioscopic findings: angle width Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.2.1 1‐year results

2

2598

Mean Difference (IV, Fixed, 95% CI)

4.93 [4.73, 5.12]

1.2.2 5‐year results

2

2016

Mean Difference (IV, Fixed, 95% CI)

5.07 [4.78, 5.36]

1.3 Gonioscopic findings: presence of peripheral anterior synechiae Show forest plot

3

Risk Ratio (IV, Fixed, 95% CI)

Subtotals only

1.3.1 1‐year results

3

2896

Risk Ratio (IV, Fixed, 95% CI)

0.62 [0.25, 1.54]

1.3.2 5‐year results

2

2738

Risk Ratio (IV, Fixed, 95% CI)

0.41 [0.24, 0.67]

1.4 Need for additional surgery to control intraocular pressure Show forest plot

1

Risk Ratio (IV, Fixed, 95% CI)

Totals not selected

1.4.1 5‐year follow‐up

1

Risk Ratio (IV, Fixed, 95% CI)

Totals not selected

1.5 Best‐corrected visual acuity Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.5.1 1‐year results

2

2596

Mean Difference (IV, Fixed, 95% CI)

0.00 [‐0.01, 0.01]

1.5.2 5‐year results

2

2002

Mean Difference (IV, Fixed, 95% CI)

0.01 [‐0.01, 0.03]

1.6 Adverse events Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.6.1 Intraocular pressure spike

1

1778

Risk Ratio (M‐H, Fixed, 95% CI)

13.00 [0.73, 230.42]

1.6.2 Acute angle closure

3

3006

Risk Ratio (M‐H, Fixed, 95% CI)

0.29 [0.07, 1.20]
Figuras y tablas -
Comparison 1. Iridotomy versus no treatment
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