Does the pilocarpine phenylephrine provocative test help in the management of acute and subacute angle closure glaucoma?

The pilocarpine phenylephrine provocative test (PPPT) has been described as a highly sensitive method to identify eyes suffering from or at risk of angle closure glaucoma (ACG). This paper reports on average 10 years follow-up of the outcome of cases of primary acute ACG and subacute ACG in which the management was determined by the result of the PPPT--a positive result indicating the need for a peripheral iridectomy, a negative result conservative treatment. In spite of a negative PPPT the fellow eyes of cases of acute ACG treated conservatively had a high rate (40%) of development of ACG. Similarly, in eyes with a history of subacute ACG with a negative PPPT, ACG developed at some stage during the follow-up in 60%. Peripheral iridectomy alone resulted in normal intraocular pressure in 63% of eyes that had suffered an attack of acute ACG. In hypertensive eyes that presented with subacute ACG, however, only one eye became normotensive following peripheral iridectomy alone. In the subacute ACG group a positive PPPT was closely related to the presence of glaucomatous optic disc damage. These results indicate that the PPPT lacks sensitivity in detecting eyes at risk of angle closure glaucoma, and a positive result is likely in eyes with damaged outflow that will not respond to peripheral iridectomy.