Regarding the management and prognosis of primary angle-closure glaucoma, all of the following statements are true EXCEPT:

Explanation

## Management and Prognosis of Primary Angle-Closure Glaucoma ### Medical Management of Acute PACG **Key Point:** Acute angle-closure glaucoma is a medical emergency requiring immediate IOP reduction before laser treatment can be safely performed. | Drug Class | Agent | Mechanism | Rationale in Acute PACG | |------------|-------|-----------|------------------------| | **Topical β-blockers** | Timolol, betaxolol | ↓ aqueous production | First-line; rapid onset | | **Topical α-2 agonists** | Brimonidine, apraclonidine | ↓ production, ↑ uveoscleral outflow | Synergistic with β-blockers | | **Topical CAI** | Dorzolamide, brinzolamide | ↓ aqueous production | Sustained effect | | **Systemic CAI** | Acetazolamide IV/PO | ↓ aqueous production | Rapid, potent; IV preferred acutely | | **Osmotic agents** | IV mannitol, oral glycerol | Shrink vitreous volume, dehydrate iris | Allows iris to fall back, deepens AC | | **Miotics** | ~~Pilocarpine~~ | ~~Constrict pupil~~ | **CONTRAINDICATED** in acute PACG—worsens angle closure | **High-Yield:** The goal of medical therapy is to lower IOP sufficiently to allow the iris to fall back and deepen the anterior chamber, making peripheral iridotomy technically feasible and safer. ### Laser Iridotomy: Definitive Treatment **Key Point:** Peripheral laser iridotomy should be performed **bilaterally** in primary angle-closure glaucoma. The contralateral eye is at high risk (often 50% or greater) of developing angle closure because it shares the same anatomical predisposition (shallow AC, hyperopia, short axial length). **Clinical Pearl:** Prophylactic iridotomy in the fellow eye prevents acute angle-closure in approximately 50% of patients who would otherwise develop it, making it a standard-of-care intervention. ### Prognosis: Acute vs. Chronic PACG **High-Yield:** Acute angle-closure glaucoma **has a WORSE prognosis than chronic angle-closure glaucoma** in terms of visual outcome, despite earlier diagnosis. This is because: 1. **Acute PACG:** Markedly elevated IOP (40–80+ mmHg) causes rapid optic nerve damage; even with prompt treatment, irreversible damage may have already occurred. 2. **Chronic PACG:** IOP elevation is more gradual, allowing some adaptation; visual loss develops insidiously but may be less severe at presentation. **Warning:** The distractor states the opposite—that acute PACG has a better prognosis. This is a common misconception. ### Role of Gonioscopy in Acute PACG **Key Point:** Gonioscopy is **NOT contraindicated** in acute angle-closure glaucoma. In fact, gonioscopy is **essential** for: - Confirming the diagnosis (visualizing angle closure) - Assessing angle anatomy and degree of closure - Guiding laser iridotomy placement - Monitoring response to medical therapy **Clinical Pearl:** Gonioscopy does NOT precipitate or worsen angle closure. The gonioscope lens actually **deepens the anterior chamber** mechanically, making it safer during acute attack. The fear that gonioscopy might worsen angle closure is unfounded and contradicts clinical practice. **High-Yield:** Gonioscopy is a diagnostic and therapeutic aid in acute PACG, not a contraindication.