Radhakrishnan reframes narrow-angle care

Sunita Radhakrishnan used a May 25, 2026 discussion in *Ophthalmology Times* to argue that narrow-angle glaucoma care should not default to laser peripheral iridotomy as the final step in many patients. She described narrow-angle disease as a group of mechanisms rather than a single problem, with management shaped by lens-related crowding, plateau iris, the extent of synechial closure and intraocular pressure behavior. The article presented laser as one tool in a broader treatment sequence, not an automatic endpoint. It also framed documentation of mechanism as a practical starting point for treatment decisions. ### Why did Radhakrishnan push back on a one-procedure approach? Sunita Radhakrishnan said the clinical mistake is to treat all narrow angles as if they behave the same way. In the *Ophthalmology Times* report, she described a need to match treatment to the underlying anatomic and pressure mechanism rather than assume that a patent iridotomy resolves the disease process in every eye. (ophthalmologytimes.com) The May 25 report said her framework separates eyes with pupillary block from eyes in which other factors continue to narrow or close the angle after laser. That distinction matters because residual crowding, plateau iris configuration or more established angle damage can leave patients at risk even after iridotomy. ### Which mechanisms did she say clinicians should identify first? (ophthalmologytimes.com) Radhakrishnan focused on lens-related crowding, plateau iris, peripheral anterior synechiae and intraocular pressure behavior as the main variables that should guide treatment. The article said those features help determine whether an eye is being managed prophylactically, has intermittent or chronic closure, or already shows glaucomatous damage. (ophthalmologytimes.com) The mechanism-first approach also changes how clinicians think about follow-up. A narrow angle found on screening is not the same as an eye with pressure elevation, symptoms or established synechial closure, and the report said Radhakrishnan urged clinicians to separate those categories in practice. ### Where does laser peripheral iridotomy still fit? Laser peripheral iridotomy remained part of the treatment pathway in the report, but not as a universal finish line. (ophthalmologytimes.com) Radhakrishnan said the procedure addresses pupillary block, while other mechanisms may continue to require treatment after the laser is done. That means an eye can have a technically successful iridotomy and still need additional management. (ophthalmologytimes.com) The article said clinicians should assess whether the angle has actually opened, whether pressure behavior has improved and whether other anatomic factors continue to drive closure. ### When did she say lens extraction or iridoplasty should enter the discussion? The *Ophthalmology Times* piece said Radhakrishnan urged earlier consideration of lens extraction when lens-related crowding is doing the main work. (ophthalmologytimes.com) It also said iridoplasty should be considered when plateau iris or persistent non-pupillary block narrowing remains part of the picture. Her comments placed those options inside a sequence built around mechanism, not around habit. (ophthalmologytimes.com) In that sequence, prophylactic cases, eyes with established synechial closure and eyes with ongoing pressure elevation do not automatically move through the same intervention list. ### What is the practical change for clinic workflow? The May 25 article said the first operational step is better documentation. (ophthalmologytimes.com) Radhakrishnan’s approach calls for recording the suspected mechanism, distinguishing prophylactic narrow-angle cases from established glaucoma, and identifying whether pressure behavior or synechial damage suggests the need for something beyond laser alone. For clinicians, that creates a more explicit decision tree at the slit lamp and in follow-up notes. The report said the next step is not a new guideline release or trial date, but a case-by-case treatment plan built around mechanism, with laser, lens extraction, iridoplasty and monitoring used according to the anatomy and pressure pattern in each eye. (ophthalmologytimes.com)