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Optometric Management

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Imaging the Anterior Segment for Narrow Angles

High-resolution anterior segment imaging can be used to guide definitive management of anatomically narrow angles.

By: Randy Charrier, OD, FAAO, Dipl CCLRT
Optometric Management March 5, 2026

Case Presentation

A 60-year-old female patient presented for routine evaluation as a narrow angle glaucoma suspect. She had been diagnosed with anatomically narrow angles 6 years earlier and was placed on nightly topical hypotensive therapy. On medication, her intraocular pressures remained stable with no evidence of progressive optic neuropathy or visual field loss.

Despite stability, the patient reported worsening dry eye symptoms, redness, and irritation, which she attributed to her evening drop use. She asked whether alternative treatment options were available.

Treatment Considerations

In cases of anatomically narrow angles without symptoms of intermittent angle closure or glaucomatous damage, management should be individualized. Options include:

Alternative Topical Therapy. For stable patients, switching to a different hypotensive agent may improve tolerability. However, this approach often requires trial and error while monitoring for maintained pressure control.

Laser Peripheral Iridotomy. For patients not ready for cataract surgery, laser peripheral iridotomy (LPI) provides a prophylactic outflow pathway to reduce the risk of acute angle closure attacks and chronic intermittent angle closure symptoms.

Cataract Extraction. If the crystalline lens demonstrates visually significant opacity or contributes substantially to anterior chamber crowding, lens extraction can be a definitive solution by deepening the anterior chamber.

Observation. Careful monitoring without intervention may be appropriate in select patients, provided they are well counseled and adhere to regular surveillance.

Imaging-Guided Decision Making

To refine surgical candidacy, anterior segment imaging was performed using the Heidelberg ANTERION SS-OCT. High-resolution imaging clearly demonstrated the following:

  • A visually clear crystalline lens, not meeting criteria for cataract extraction
  • Markedly narrow angles at iris insertion
  • Angle measurements in the single-digit degrees

These findings supported LPI as the most appropriate intervention.

Figure 1. OD with angle markings. ANTERION SS-OCT image of the patient’s right eye with calculated markings displaying iris tissue at narrow temporal and nasal insertions of 9 degrees and 3 degrees, respectively.
Figure 2. OD without angle markings. ANTERION SS-OCT image of the patient’s right eye anterior chamber angle. This image is taken in the horizontal nasal-temporal plane and displays a crowded and narrow insertion angle of the iris root with respect to the cornea and scleral spur.
Figure 3. OS with angle markings. ANTERION SS-OCT image of the patient’s left eye with calculated markings displaying iris tissue at narrow nasal and temporal insertions of 7 degrees and 6 degrees, respectively.
Figure 4. OS without angle markings. ANTERION SS-OCT image of the patient’s left eye anterior chamber angle. This image is taken in the horizontal nasal-temporal plane and displays a crowded and narrow insertion angle of the iris root with respect to the cornea and scleral spur.

After discussing continued medical therapy, medication adjustment, observation, and LPI, the patient elected to proceed with LPI. The procedure was well tolerated. At follow-up, intraocular pressure, optic nerve appearance, and visual field testing remained stable.

Clinical Takeaway

Advanced anterior segment imaging allows efficient, objective evaluation of angle anatomy and surgical candidacy. In this case, imaging supported a definitive intervention that spared the patient years of chronic drop burden and improved her ocular surface discomfort, all while maintaining stable glaucoma surveillance outcomes.

Randy Charrier, OD, FAAO, Dipl CCLRT

Randy Charrier, OD, FAAO, Dipl CCLRT, is an associate professor at the University of Houston College of Optometry.

This content is sponsored by Heidelberg