Angle Recession Glaucoma Clinical Presentation

  • Author: Brian R Sullivan, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Apr 18, 2012
 

History

Although nonpenetrating eye trauma invariably precedes angle recession, the patient may forget details of the injury or the entire episode after a number of years have passed. In addition, patients with angle-recession glaucoma, like patients with other forms of glaucoma, may present with no specific eye or visual complaints.

  • A unilateral cataract in a young or middle-aged adult should raise the suspicion of remote trauma, even when the history is negative.
  • In cases of suspected traumatic angle recession, careful history taking may elicit otherwise forgotten information.
  • In elderly patients, rule out a history of falls.
  • Some patients do not report any history of trauma despite extensive questioning. Lack of a positive history does not rule out angle recession.
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Physical

Unilateral elevation of IOP is a hallmark finding in angle-recession glaucoma, but it may not be noted in early stages of the disorder.

  • Ideally, angle recession should be discovered before glaucoma develops so that the risk of glaucoma can be assessed and follow-up care arranged accordingly.
  • High IOPs noted early after injury (within the first few months of injury) may indicate extensive trabecular damage and a poor prognosis.
  • Angle recession is typically diagnosed by means of gonioscopy.
    • The clinical appearance of the affected angle varies with the depth of the tear in the ciliary body and with the amount of time passed after the injury.
    • Typically, an irregularly wide ciliary body band is visible with retroplacement of the iris root. The angle appears abnormally deep in the involved areas. This characteristic appearance is due to a cleavage between the longitudinal and circular muscles of the ciliary body. After years of healing, the fissure may no longer be visible. In fact, when many years have passed after the contusional injury, angle recession may be difficult to recognize.
    • A large series of blunt injuries among soccer players found that angle recession is more likely to occur in the superotemporal quadrant.[16]
  • Comparison with the angles in the injured and uninjured eyes is important, particularly in cases with subtle findings. Documented asymmetry supports the diagnosis.
  • Ipsilateral anterior chamber depth may be increased following a contusion injury even if other signs of angle recession are absent.[26]
  • Angle recession should be differentiated from cyclodialysis, which is the disinsertion of the ciliary body from its attachment to the scleral spur.
  • A number of anterior segment abnormalities often accompany angle recession:
    • Cyclodialysis
    • Iridodialysis
    • Iridoschisis
    • Anterior synechia
    • Iris sphincter tears
    • Mydriasis
    • Iris atrophy
    • Transillumination defects
    • Iritis
    • Zonular breaks
    • Phacodonesis
    • Subluxated lens
    • Cataract
  • Ultrasound biomicroscopy (UBM) is a useful adjunctive modality for the evaluation of abnormalities in closed-globe injuries (see Imaging Studies).[27]
  • A strong association exists between hyphema and angle recession, but the ciliary body also can be severely damaged from blunt trauma, without the appearance of a hyphema.
  • Posterior segment abnormalities, which may signify prior episodes of trauma, include the following:
    • Vitreous opacities
    • Chorioretinal scars
    • Macular hole
    • Retinal breaks
    • Retinal detachment
    • Optic atrophy
  • An uncontrolled and sustained elevation in IOP in angle-recession glaucoma, as in other forms of glaucoma, ultimately leads to progressive cupping of the optic nerve and loss of the visual field.
  • Snellen visual acuity is typically uninvolved until the late stages of glaucoma.
  • Formal visual field testing is of paramount importance in diagnosing and monitoring the disorder.Gonioscopic examination many years after blunt traGonioscopic examination many years after blunt trauma in a patient with angle-recession glaucoma. Note the irregular contour of the iris, with loss of detail of angle structures. Classic findings of angle recession may become subtle or be obscured over time.
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Causes

Any cause of nonpenetrating ocular trauma can result in angle-recession glaucoma. The episode may be seemingly trivial and forgotten. The circumstances of the injury can be variable, often involving trauma from high-velocity blunt objects or projectiles (eg, stones, balls, champagne stoppers, bungee cords, toys, tree branches, fruit, airbags, fists). Ocular surgery, such as penetrating keratoplasty[28] or cataract extraction, may also result in angle recession.

The most common types of blunt trauma are the following:

  • Sports injuries (eg, boxing, paintball, airsoft gun toys)[18, 13, 12]
  • Motor vehicle accidents (eg, airbag deployment, other facial trauma)
  • Assaults
  • Falls
  • Military combat injuries
  • Accidents (eg, industrial, farm, home, bungee cord injuries)[11]
  • Other (eg, school accidents, natural disasters)
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Contributor Information and Disclosures
Author

Brian R Sullivan, MD  Professor, Department of Ophthalmology, University of Texas Southwestern Medical Center

Brian R Sullivan, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew I Rabinowitz, MD  Consulting Staff, Department of Ophthalmology, Barnet Dulaney Perkins Eye Center

Andrew I Rabinowitz, MD is a member of the following medical societies: Aerospace Medical Association, American Academy of Ophthalmology, and American Medical Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Martin B Wax, MD  Clinical Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Ophthalmology Research and Development, Head, Ophthalmology Discovery Research, Alcon Labs, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Society for Neuroscience

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Supported in part by an unrestricted research grant from Research to Prevent Blindness, Inc., New York, NY

Dr. Sullivan has no financial interests in any of the products mentioned in this article, nor in any of the companies that manufacture or distribute them.

References

  1. Shields MB, ed. Glaucomas associated with ocular trauma. In: Textbook of Glaucoma. 4th ed. Baltimore: Lippincott Williams & Williams; 1988:339-44.

  2. Wolff SM, Zimmerman LE. Chronic secondary glaucoma. Association with retrodisplacement of iris root and deepening of the anterior chamber angle secondary to contusion. Am J Ophthalmol. 1962;84:547-63.

  3. Sihota R, Sood NN, Agarwal HC. Traumatic glaucoma. Acta Ophthalmol Scand. Jun 1995;73(3):252-4. [Medline].

  4. Sponsel WE, Gray W, Scribbick FW, Stern AR, Weiss CE, Groth SL, et al. Blunt eye trauma: empirical histopathologic paintball impact thresholds in fresh mounted porcine eyes. Invest Ophthalmol Vis Sci. Jul 2011;52(8):5157-66. [Medline].

  5. Sihota R, Kumar S, Gupta V, et al. Early predictors of traumatic glaucoma after closed globe injury: trabecular pigmentation, widened angle recess, and higher baseline intraocular pressure. Arch Ophthalmol. Jul 2008;126(7):921-6. [Medline].

  6. Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular contusion: a cohort study of the United States Eye Injury Registry. J Glaucoma. Dec 2005;14(6):470-3. [Medline].

  7. Ozer PA, Yalvac IS, Satana B, Eksioglu U, Duman S. Incidence and risk factors in secondary glaucomas after blunt and penetrating ocular trauma. J Glaucoma. Dec 2007;16(8):685-90. [Medline].

  8. Mowatt L, Chambers C. Ocular morbidity of traumatic hyphema in a Jamaican hospital. Eur J Ophthalmol. May-Jun 2010;20(3):584-9. [Medline].

  9. Glynn RJ, Seddon JM, Berlin BM. The incidence of eye injuries in New England adults. Arch Ophthalmol. Jun 1988;106(6):785-9. [Medline].

  10. Strahlman E, Elman M, Daub E, Baker S. Causes of pediatric eye injuries. A population-based study. Arch Ophthalmol. Apr 1990;108(4):603-6. [Medline].

  11. Chorich LJ 3rd, Davidorf FH, Chambers RB, Weber PA. Bungee cord-associated ocular injuries. Am J Ophthalmol. Feb 1998;125(2):270-2. [Medline].

  12. Endo S, Ishida N, Yamaguchi T. Tear in the trabecular meshwork caused by an airsoft gun. Am J Ophthalmol. May 2001;131(5):656-7. [Medline].

  13. Fineman MS, Fischer DH, Jeffers JB, Buerger DG, Repke C. Changing trends in paintball sport-related ocular injuries. Arch Ophthalmol. Jan 2000;118(1):60-4. [Medline].

  14. Roller RA, Almond NB, Anderson W. Traumatic iridodialysis in a student naval aviator applicant. Aviat Space Environ Med. Feb 2005;76(2):147-50. [Medline].

  15. Morris DS. Ocular blunt trauma: loss of sight from an ice hockey injury. Br J Sports Med. Mar 2006;40(3):e5; discussion e5. [Medline].

  16. Capao Filipe JA, Fernandes VL, Barros H, Falcao-Reis F, Castro-Correia J. Soccer-related ocular injuries. Arch Ophthalmol. May 2003;121(5):687-94. [Medline].

  17. Vize CJ, Gauba V, Atkinson PL. Eye injury as a result of coat toggle trauma. Eye. Jan 2007;21(1):94-5. [Medline].

  18. Giovinazzo VJ, Yannuzzi LA, Sorenson JA, Delrowe DJ, Cambell EA. The ocular complications of boxing. Ophthalmology. Jun 1987;94(6):587-96. [Medline].

  19. McCarty CA, Fu CL, Taylor HR. Epidemiology of ocular trauma in Australia. Ophthalmology. Sep 1999;106(9):1847-52. [Medline].

  20. Nwosu SN. Domestic ocular and adnexal injuries in Nigerians. West Afr J Med. Jul-Sep 1995;14(3):137-40. [Medline].

  21. Koval R, Teller J, Belkin M, Romem M, Yanko L, Savir H. The Israeli Ocular Injuries Study. A nationwide collaborative study. Arch Ophthalmol. Jun 1988;106(6):776-80. [Medline].

  22. Desai P, MacEwen CJ, Baines P, Minassian DC. Epidemiology and implications of ocular trauma admitted to hospital in Scotland. J Epidemiol Community Health. Aug 1996;50(4):436-41. [Medline].

  23. Salmon JF, Mermoud A, Ivey A, Swanevelder SA, Hoffman M. The detection of post-traumatic angle recession by gonioscopy in a population-based glaucoma survey. Ophthalmology. Nov 1994;101(11):1844-50. [Medline].

  24. Poon A, McCluskey PJ, Hill DA. Eye injuries in patients with major trauma. J Trauma. Mar 1999;46(3):494-9. [Medline].

  25. Desai P, MacEwen CJ, Baines P, Minassian DC. Incidence of cases of ocular trauma admitted to hospital and incidence of blinding outcome. Br J Ophthalmol. Jul 1996;80(7):592-6. [Medline].

  26. Kashiwagi K, Tateno Y, Kashiwagi F, Tsukahara S. Changes in Anterior Chamber Depth due to Contusion. Ophthalmic Res. Aug 7 2009;42(4):193-198. [Medline].

  27. Ozdal MP, Mansour M, Deschênes J. Ultrasound biomicroscopic evaluation of the traumatized eyes. Eye. May 2003;17(4):467-72. [Medline].

  28. Rumelt S, Bersudsky V, Blum-Hareuveni T, Rehany U. Preexisting and postoperative glaucoma in repeated corneal transplantation. Cornea. Nov 2002;21(8):759-65. [Medline].

  29. Berinstein DM, Gentile RC, Sidoti PA, et al. Ultrasound biomicroscopy in anterior ocular trauma. Ophthalmic Surg Lasers. Mar 1997;28(3):201-7. [Medline].

  30. Iwamoto T, Witmer R, Landolt E. Light and electron microscopy in absolute glaucoma with pigment dispersion phenomena and contusion angle deformity. Am J Ophthalmol. Aug 1971;72(2):420-34. [Medline].

  31. Bai HQ, Yao L, Wang DB, Jin R, Wang YX. Causes and treatments of traumatic secondary glaucoma. Eur J Ophthalmol. Mar-Apr 2009;19(2):201-6. [Medline].

  32. Fukuchi T, Iwata K, Sawaguchi S, Nakayama T, Watanabe J. Nd:YAG laser trabeculopuncture (YLT) for glaucoma with traumatic angle recession. Graefes Arch Clin Exp Ophthalmol. Oct 1993;231(10):571-6. [Medline].

  33. Mermoud A, Salmon JF, Straker C, Murray AD. Post-traumatic angle recession glaucoma: a risk factor for bleb failure after trabeculectomy. Br J Ophthalmol. Oct 1993;77(10):631-4. [Medline].

  34. Manners T, Salmon JF, Barron A, Willies C, Murray AD. Trabeculectomy with mitomycin C in the treatment of post-traumatic angle recession glaucoma. Br J Ophthalmol. Feb 2001;85(2):159-63. [Medline].

  35. de Klerk TA, Au L. I-stent for treatment of angle recession with raised intraocular pressure. Clin Experiment Ophthalmol. Nov 2 2011;[Medline].

  36. Melamed S, Ashkenazi I, Gutman I, Blumenthal M. Nd:YAG laser trabeculopuncture in angle-recession glaucoma. Ophthalmic Surg. Jan 1992;23(1):31-5. [Medline].

  37. Canavan YM, Archer DB. Anterior segment consequences of blunt ocular injury. Br J Ophthalmol. Sep 1982;66(9):549-55. [Medline].

  38. Tesluk GC, Spaeth GL. The occurrence of primary open-angle glaucoma in the fellow eye of patients with unilateral angle-cleavage glaucoma. Ophthalmology. Jul 1985;92(7):904-11. [Medline].

 
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Irregular widening of the visible ciliary body in a quadrant with angle recession.
Angle recession. Note the marked posterior displacement of the iris, with a wide ciliary body band posterior to the scleral spur.
Gonioscopic examination many years after blunt trauma in a patient with angle-recession glaucoma. Note the irregular contour of the iris, with loss of detail of angle structures. Classic findings of angle recession may become subtle or be obscured over time.
 
 
 
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