Glaucoma, Angle Recession Treatment & Management

  • Author: Brian R Sullivan, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Apr 29, 2010
 

Medical Care

The necessity of initiating treatment of angle-recession glaucoma depends on the severity of the initial injury and the somewhat variable clinical course as healing progresses. Normotensive eyes with angle recession of more than 180° should be routinely reexamined for an indefinite period to monitor for the development of late glaucoma.

  • In patients with an abnormal elevation of IOP, the decision to begin therapy is based on the clinician's overall assessment of the risk of vision loss.
    • The severity of IOP elevation, optic nerve appearance, and visual field findings contribute to the decision-making process.
    • Treatment almost always is indicated when the IOP is greater than an arbitrary range of 25-28 mm Hg and/or when glaucomatous optic nerve or visual field changes are documented over time.
  • After the diagnosis of angle recession is established, its management is similar to that of POAG, with a few special considerations.
    • Use of topical aqueous suppressants in the initial medical treatment is preferred; these include beta-antagonists, alpha-agonists, and carbonic anhydrase inhibitors.
    • Prostaglandin analogs, which increase uveoscleral outflow, have a theoretical benefit in angle recession because the trabecular meshwork is thought to be dysfunctional in such cases.
    • Use caution in administering miotic agents because pilocarpine has been reported to cause a paradoxical elevation of IOP in angle recession, presumably due to a reduction of uveoscleral outflow.
    • Atropine has been reported to reduce IOP in angle-recession glaucoma; therefore, cycloplegic agents may have a role in treatment.
    • A trial of a cycloplegic agent should be reserved either for cases involving failure of conventional glaucoma therapy or for cases with other indications for cycloplegia (eg, inflammation).
  • The response to medical therapy in angle-recession glaucoma is variable.
    • Topical medical treatment may be effective in cases of mild-to-moderate angle recession, while elevated IOP of eyes with extensive angle injury eventually may become refractory to medications.
    • Severe early cases may fail to show an initial response to aggressive medical treatment, indicating a poorer overall prognosis.
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Surgical Care

Surgical intervention in angle-recession glaucoma is usually indicated when maximally tolerated medical treatment has failed[29] and when the risk of progressive visual loss outweighs the estimated risk of the planned surgical management. In general, outcomes of surgical treatment are less favorable than those of POAG.

  • Argon laser trabeculoplasty
    • Argon laser trabeculoplasty (ALT) has been associated with short-term success, though the procedure has been reported to have poor long-term effectiveness, particularly in eyes with more than 180° of angle recession.
    • IOP elevation may become worse in response to ALT.
    • In eyes with less than 180° of angle recession, ALT may be beneficial if applied to only the trabecular meshwork of the nonrecessed portions of the anterior-chamber angle.
  • Alternative laser procedures
    • Nd:YAG laser trabeculopuncture (YLT) has been used with variable success. A 1992 study demonstrated a 100% failure rate in eyes with 360° angle recession.[30]
    • Currently, YLT is not recommended for the routine management of angle-recession glaucoma.
    • Other laser procedures that have shown promise are transscleral krypton laser cyclophotocoagulation, transpupillary argon laser cyclophotocoagulation, and endoscopic cyclophotocoagulation.
  • Filtration surgery
    • Filtration surgery has a success rate lower than that of POAG.
    • Trabeculectomy in eyes with angle recession is associated with decreased postoperative reduction in IOP, increased rates of bleb fibrosis and bleb failure, and increased dependence on postoperative medical treatment of glaucoma.[31]
    • The adjunctive use of antimetabolites, particularly mitomycin C, can improve the success of trabeculectomy. This finding suggests that an antimetabolite should be used during the initial filtering procedure. A 2001 report described effective results with an acceptable complication rate in such cases.[32]
  • Tube shunt devices
    • Benefits with the implantation of tube shunt devices have been demonstrated, but outcomes are reportedly less successful in angle recession than in other types of refractory glaucoma.
    • A 1993 study showed the superior results of trabeculectomy with antimetabolite over Molteno implantation in cases of posttraumatic angle-recession glaucoma.
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Consultations

  • Consultation with a glaucoma specialist should be considered in cases with an uncertain diagnosis, with early severe IOP elevation, with a poor response to treatment, or with advanced visual field loss.
  • Depending on the presence of other posttraumatic ocular or orbital abnormalities, consider referring the patient to subspecialists in corneal and/or external disease, oculoplastics retinal disease, or neuro-ophthalmology.
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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.

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  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.

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.

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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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