Performing goniosynechiolysis at the slit lamp can be effective for selected eyes with peripheral anterior synechiae (PAS) following angle closure. Under topical anesthesia and with aseptic technique, a 30-gauge needle is introduced via the limbus. Under direct gonioscopic view, the needle is gently advanced to engage and sweep the peripheral iris away from the trabecular meshwork. Minimal force is used to avoid bleeding or iris dialysis. Aqueous flow restoration is confirmed by widening of the angle structures. Then performing goniosynechiolysis in the operating room can be done which is typically performed after phacoemulsification. The irrigation/aspiration (I/A) probe is introduced with low vacuum and controlled aspiration, the tip engages the iris near the area of adhesion, applying gentle suction to peel it off the trabecular meshwork. The goal is to separate the synechiae while minimizing trauma to the iris and angle structures. Viscoelastic may be reapplied to maintain chamber depth. This technique allows broad synechial release with excellent visualization and can significantly improve aqueous outflow postoperatively.
