eMedicine Specialties > Ophthalmology > Intraocular Pressure

Glaucoma, Angle Recession: Differential Diagnoses & Workup

Author: Brian R Sullivan, MD, Associate Professor, Department of Ophthalmology, University of Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: Jan 21, 2009

Differential Diagnoses

Glaucoma, Angle Closure, Acute
Glaucoma, Primary Open Angle
Glaucoma, Angle Closure, Chronic
Glaucoma, Pseudoexfoliation
Glaucoma, Lens-Particle
Glaucoma, Unilateral
Glaucoma, Neovascular
Glaucoma, Uveitic
Glaucoma, Phacolytic
Melanoma, Ciliary Body
Glaucoma, Pigmentary
Melanoma, Iris

Other Problems to Be Considered

Elevated episcleral venous pressure/carotid cavernous fistula
Iridocorneal endothelial (ICE) syndrome
Uveitis-glaucoma-hyphema (UGH) syndrome

Angle recession refers to a tear between the circular and longitudinal fibers of the ciliary body. Cyclodialysis is defined as a detachment of the ciliary body from its insertion at the scleral spur. Iridodialysis is separation of the iris root from its attachment to the anterior ciliary body. By comparison, iridoschisis refers to splitting of layers of iris stroma. All of these conditions are sequelae of blunt ocular trauma, and any of these conditions may coexist.

Workup

Imaging Studies

  • The diagnosis of angle recession is confirmed during office examination.
  • Usually, imaging is necessary only to evaluate comorbidities due to trauma.
    • Occasionally, CT scanning of the orbits is needed to evaluate for orbital fractures or foreign bodies.
    • Emergency neuroimaging if typically indicated after major head trauma.
  • On occasion, gonioscopy is difficult or impossible in traumatized eyes because of corneal edema, corneal scarring, hyphema, synechia, or other opacity. In such cases, high-frequency ultrasound biomicroscopy (as a supplemental tool to standard office examination) is effective for evaluating abnormalities of the angle in the anterior chamber.22
    • Ultrasound biomicroscopy produces high-resolution axial images of the anterior globe, providing cross-sectional views of the angle in vivo similar to those of a histologic section.
    • This noninvasive procedure is readily performed in a clinical setting in an intact globe, and it provides information otherwise unavailable from convention examination.
    • High-resolution images of angle recession, iridodialysis, and cyclodialysis have been described.
    • Ultrasound biomicroscopy findings of a wider angle and absence of cyclodialysis have been reported to be significant predictors for the development of traumatic glaucoma in eyes with closed globe injury.4

Other Tests

  • Because progressive loss of visual field is a potential outcome, formal visual field testing is the most important adjunctive diagnostic modality in detecting and following up the disorder.
  • Several authors have described the use of tonography to evaluate patients with traumatic angle recession.
    • Loss of outflow facility, as measured on tonographic studies, is common after angle-recession injuries, and this finding is statistically significant in cases of angle recession as a group.
    • However, role of tonography in predicting the risk of glaucoma appears to be of little value in any single case.
    • Tonography might not be available to the average practitioner, and it is currently an unnecessary adjunct to the evaluation and management of angle recession.
  • Optic nerve photography is also important for documenting and monitoring glaucoma.
  • Computerized disk analysis and analysis of nerve-fiber layers has been gaining acceptance in the diagnosis and management of all forms of glaucoma.

Procedures

  • Gonioscopy is the only clinical procedure that must be performed before angle recession can be diagnosed.
    • Use of a 1- or 3-mirror Goldman goniolens, which provides the greatest magnification of angle structures, is recommended.
    • Use of the Koeppe lens for examining and photographing the anterior chamber angle is also advocated. Use of Koeppe lenses allows for easy comparison with the uninjured eye because they can be placed simultaneously on the eyes.
    • The Posner 4-mirror gonioprism is not preferred for evaluating suspected angle recession because of the potential for indenting the central cornea, inducing artificial deepening, and/or distorting of the anterior-chamber angle.

Histologic Findings

Histopathologic findings of eyes with angle-recession deformities have been well described and include features of both light microscopy and electron microscopy (EM).

In their classic report in 1962, Wolf and Zimmerman described a characteristic tear extending into the anterior ciliary body, separating the longitudinal and circular fibers.2

  • The extent of dissection varied, but the longitudinal muscle remained attached to the scleral spur.
  • Retroplacement of the iris root and ciliary processes was noted microscopically. An association with other abnormal findings, including iridodialysis, rupture of the trabecular meshwork, or cyclodialysis, was documented. Late findings were also reported.
  • Over time, healing of the ciliary body laceration was noted. This was accompanied by atrophy of the circular muscle at involved sites, resulting in a fusiform contour of the ciliary body, as seen on axial sections.
  • Other histopathologic findings in late cases provided clues to the mechanism of glaucoma in angle recession. Marked degeneration of the trabecular meshwork was prominent.
  • In some cases, an abnormal hyaline membrane, continuous with the Descemet membrane, was formed over the inner surface of the trabecular meshwork, sometimes extending further onto the anterior iris surface.
    • Abnormal corneal endothelial proliferation may occur in some eyes with traumatic angle deformities.
    • The histologic examination revealed proliferation of the endothelium posterior to the Schwalbe ring with secretion of a Descemetlike membrane covering the meshwork and perhaps reducing trabecular outflow capacity of the involved angle.
    • Electron microscopy of some eyes with angle recession may verify the presence of a hyaline membrane over the inner trabecular region, with an endothelial layer structurally similar to that of normal corneal endothelium. Other electron microscopy findings include loss of intertrabecular spaces and a decrease or absence of the trabecular endothelial cells. Thickening of the juxtacanicular connective tissue has been observed, with loss of vacuole lining within the endothelial cells lining the inner wall of the Schlemm canal.23

Although the exact pathology of angle-recession glaucoma is not fully established, the ultrastructural abnormalities described above support a chronic progressive mechanism of trabecular outflow dysfunction, leading to pressure elevation over time.

More on Glaucoma, Angle Recession

Overview: Glaucoma, Angle Recession
Differential Diagnoses & Workup: Glaucoma, Angle Recession
Treatment & Medication: Glaucoma, Angle Recession
Follow-up: Glaucoma, Angle Recession
Multimedia: Glaucoma, Angle Recession
References
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References

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  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.

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Further Reading

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Keywords

angle-recession glaucoma, angle recession glaucoma, posttraumatic angle-recession glaucoma, contusion angle-recession glaucoma, contusion angle deformity, traumatic glaucoma, traumatic angle-recession glaucoma, intraocular pressure, IOP, optic neuropathy, open-angle glaucoma

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Contributor Information and Disclosures

Author

Brian R Sullivan, MD, Associate 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.

Medical Editor

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.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
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.

Managing Editor

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: Alcon Labs Salary Employment

CME Editor

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.

 
 
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