eMedicine Specialties > Ophthalmology > Intraocular Pressure

Glaucoma, Angle Recession: Follow-up

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

Updated: Jan 21, 2009

Follow-up

Further Outpatient Care

  • As in other types of glaucoma, follow-up depends on the degree of IOP control and the risk of progressive loss of the visual field.
  • Patients with an early increase in IOP after blunt trauma should be reexamined every 4-6 weeks during the first year to monitor their condition.
    • Some early cases are self-limited, but patients should still be observed after their condition appears to resolve.
    • Other early cases represent a severe form of the disease that may be refractory to standard medical treatment; such cases warrant more frequent follow-up.
  • In cases of angle recession of greater than 180° that initially have no evidence of glaucoma, late-onset glaucoma can potentially occur, even many years after the injury. Annual examinations should be performed for an indefinite period.

Inpatient & Outpatient Medications

Deterrence/Prevention

  • The incidence of angle-recession glaucoma can be reduced by preventing the underlying trauma.
  • Data indicate that most pediatric and adult eye injuries (eg, sports-related accidents) are preventable.
  • Public education on the use of eye, face, or head protection during high-risk activities may lower the incidence of ocular injuries.
  • Public safety standards to reduce rates of eye injury can be achieved by enacting legislative policies such as seatbelt or helmet laws.

Complications

  • Nonglaucomatous comorbidity in eyes with angle recession increases the risk of vision loss. Traumatic insults to the cornea, iris, lens, vitreous, retina, or optic nerve may contribute to vision-threatening sequelae.
  • Traumatic cataract often accompanies angle recession.
    • Gonioscopy should always be performed when a patient with a unilateral cataract is evaluated, even when his or her history is negative for trauma.
    • After surgical management, the risk of complications is higher with a traumatic cataract than with a senile cataract.
  • Intraoperative complications include the following:
    • Zonular dialysis
    • Vitreous loss
    • Intraocular hemorrhage
    • Inadequate posterior intraocular lens (IOL) support: Zonular injury is a common finding in such cases. When zonular defects are small, placement of the IOL into the capsular bag usually can be achieved without further complication. Placement of an anterior-chamber IOL is not preferred in eyes with even minimal angle recession, and it is fully contraindicated when the angle is recessed more than 180°.
  • Postoperative complications
    • IOP elevation
    • Inflammation
    • IOL malposition
    • Pupil capture
    • Intraocular hemorrhage
    • Glare
    • Monocular diplopia: Symptoms may result from iris abnormalities.
  • Cataract extraction in eyes with known angle-recession deformities should be approached with caution.
  • The most common posterior-segment complications after blunt trauma include macular lesions and peripheral retinal tears.
    • Posttraumatic entities involving the macula include the following:
      • Macular cysts
      • Macular holes
      • Hyperplastic-atrophic pigment epitheliopathy
      • Choroidal rupture: This is another possible finding in traumatized eyes and sometimes leads to secondary neovascular degeneration or disciform scarring.
    • Traumatic abnormalities of the peripheral retina include the following:
      • Atrophic holes
      • Horseshoe tears
      • Operculated tears
      • Retinal dialysis
      • Retinal detachment

Prognosis

  • No formal data indicate the long-term visual outcomes of eyes with chronic angle-recession glaucoma. Eyes that develop early-onset angle-recession glaucoma are thought to represent a subgroup with most extensive angle injury, but the visible degree of angle recession is not correlated with the severity of glaucoma in this group.
  • Late-onset angle-recession glaucoma almost always occurs in eyes with more than 180° of angle recession, and the risk appears to increase with the extent of angle recession. Eyes with a 360° angle recession are at greatest risk.
  • As in most types of glaucoma, angle-recession glaucoma can cause progressive visual field loss and blindness.27
    • The risk of visual loss depends on many factors, particularly the timeliness of initial diagnosis and the course of management.
    • Response of elevated IOP to medical therapy varies, and with time, IOP control may deteriorate despite dependence on multiple medications.
    • Favorable results have been reported for surgical intervention of angle-recession glaucoma, but success rates are lower than those of other forms of glaucoma.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Medicolegal concerns may arise from an allegation of a failure to diagnose the disorder or from delays in providing appropriate care.
    • Angle recession should be suspected in any patient with a unilateral cataract or with a history of eye injury, even if the traumatic event seems trivial.
    • Gonioscopy should be routinely performed in the evaluation of a patient with a history—even a remote history—of blunt trauma, particularly after a hyphema resolves.
    • Gonioscopy should be performed in all patients with suspected POAG.
    • Angles should be examined in patients with asymmetric IOPs, unilateral cataract, zonular weakness, iridodialysis, or other abnormalities of the anterior segment.
  • Failure to recommend appropriate follow-up care is a pitfall.
    • Patients with greater than 180° of angle recession should receive lifelong follow-up care, usually on an annual basis, to monitor for the development of glaucoma.
    • Patients should not be discharged from clinic because the onset of glaucoma may be many years after the injury.
  • Suboptimal monitoring of the relative effectiveness of the treatment provided is another pitfall.
    • Angle-recession glaucoma responds to both medical and surgical interventions somewhat unpredictably and with less favorable results than those of other types of glaucoma.
    • Adjustments to therapy or proceeding to more aggressive treatment measures may need to be accelerated in eyes with recalcitrant glaucoma.
    • Progression of visual field loss during a period with few or no changes in patient care may lead to medicolegal complaints or claims of an inappropriate treatment delay.

Special Concerns

  • Sickle cell anemia or trait is a systemic disorder that has multiple links to eye disease; therefore, it should be considered during the evaluation and treatment of patients with hyphema in the immediate period after blunt trauma.
  • Sickle cell anemia is a concern during the long-term management of eyes that develop angle-recession glaucoma because of the increased tendency for microvascular occlusions.
  • In general, patients with sickle cell anemia require more aggressive IOP control with glaucoma treatment than other patients because their eyes have a decreased tolerance of even moderate elevations in IOP.
  • In addition, carbonic anhydrase inhibitors and hyperosmotic agents are contraindicated in patients with sickle cell disease because of the effects of acidosis and diuresis.
 
Acknowledgments

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. 



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References
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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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