A patient with primary angle closure suspect (PACS) is found to have a narrow angle with peripheral anterior synechiae (PAS) in 4 clock hours and IOP of 26 mmHg with normal optic disc. The next step in management is:

• A Observe without treatment as IOP is only mildly elevated
• B Immediate trabeculectomy
• C Systemic acetazolamide and pilocarpine drops
• D Nd:YAG laser peripheral iridotomy (LPI) ✓

Explanation

The finding of PAS in 4 clock hours in a narrow angle upgrades the classification from PACS to primary angle closure (PAC). LPI is the definitive treatment for PAC/PACG, as it creates a hole in the peripheral iris to bypass the pupillary block mechanism, deepening the anterior chamber angle and preventing further peripheral anterior synechiae formation and angle closure. LPI should be performed bilaterally (fellow eye is also at risk). Medical therapy with acetazolamide and pilocarpine is used acutely for elevated IOP but does not definitively treat the underlying anatomical predisposition.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.