Angle Recession Glaucoma Clinical Presentation

Updated: May 31, 2017
  • Author: Brian R Sullivan, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Presentation

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. [18]
  • 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. [29]
  • 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, as follows:
    • 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), [30] and UBM may be superior to slit-lamp optical coherence tomography (SL-OCT) to image angle recession. [31]
  • A strong association exists between traumatic hyphema and angle recession, [10] but the ciliary body also can be severely damaged from blunt trauma, without the appearance of a hyphema. Gross hyphema and traumatic microhyphema are associated with approximately the same increased long-term risks of angle recession and glaucoma. [2, 10]
  • 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 tra 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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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 [32] 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) [20, 15, 14]
  • Motor vehicle accidents (eg, airbag deployment, other facial trauma)
  • Assaults
  • Falls
  • Military combat injuries
  • Accidents (eg, industrial, farm, home, bungee cord injuries) [13]
  • Other (eg, school accidents, natural disasters)
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