Getting Back to Basics in Angle Surgery

Clinical Report: Getting Back to Basics in Angle Surgery

Overview

At the 2026 AAO Glaucoma Subspecialty Day, Elena Bitrian, MD, described practical principles for angle surgery: obtain a clear view of the angle, handle instruments delicately and precisely, and maintain awareness of intraocular anatomy. She advised not proceeding with treatment when the anatomy is uncertain and discussed troubleshooting visualization challenges, including cloudy corneas.

Background

Angle surgery depends on visualization of the angle and accurate instrument positioning. Bitrian’s presentation focused on foundational surgical practices taught to glaucoma fellows, despite the availability of advanced technology. The related article on gonioscopy describes it as a valuable diagnostic tool for glaucoma evaluation and management. The supplied AAO 2026 Preferred Practice Pattern context identifies current guidance for primary open-angle glaucoma and primary angle-closure disease as a reference framework for evaluation and surgical management.

Data Highlights

The source article reports no numerical or trial data. It describes practical surgical guidance: angle instruments upward by 15 degrees, manage intraoperative bleeding, and do not proceed when the anatomy is uncertain.

Key Findings

Bitrian emphasized obtaining adequate visualization of the angle before and during angle surgery.
She advised delicate, precise instrument handling and angling instruments upward by 15 degrees.
She highlighted intraoperative bleeding management as part of the surgical approach.
She stated that treatment should not proceed when the surgeon is unsure of the anatomy.
Her presentation addressed troubleshooting visualization challenges, including operating through cloudy corneas.
The related gonioscopy article describes gonioscopy as a valuable diagnostic tool despite the availability of advanced imaging technologies.

Clinical Implications

The source supports prioritizing angle visualization, anatomical orientation, and controlled instrument handling during angle surgery. When anatomy is uncertain, Bitrian’s stated approach is not to proceed with treatment; her presentation also covered methods to improve visualization in challenging cases.

Conclusion

Bitrian’s presentation returned to foundational principles of angle surgery: see the angle clearly, handle instruments precisely, manage bleeding, and remain oriented to the anatomy. She emphasized withholding treatment when that orientation is uncertain.