Chan et al. reviewed strategies for the initial management of acute primary angle closure (APAC) [1]. We feel that the authors have overlooked a quick, low-risk option: corneal indentation (indentation gonioscopy, IG).

We find that IG is a quick, easy, patient-friendly technique that often gives an immediate reduction in intra-ocular pressure (IOP) in APAC. The technique requires a standard small diameter four-mirror gonioscopy contact lens without flange (e.g. Posner or Sussman type). In APAC, gonioscopy will confirm closed angle, but gentle pressure on the gonio-lens may allow the angle to open, at least in part [2]. In this case, all that ophthalmologist needs to do is to sustain this pressure, keeping the angle open to allow outflow of aqueous. The patient should be warned of possible discomfort. We like to re-measure the IOP after 10–20 s of indentation; if the IOP has reduced, indentation may be repeated. Successful IG can give a rapid reduction of IOP. This may translate to immediate improvement of symptoms, fewer medications, avoidance of more risky procedures, and more rapid progression to a more definitive treatment such as laser iridotomy.

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