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.
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.
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Ideally, angle recession should be discovered before glaucoma develops so that the risk of glaucoma can be assessed and follow-up care arranged accordingly.
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High IOPs noted early after injury (within the first few months of injury) may indicate extensive trabecular damage and a poor prognosis.
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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. [20]
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Comparison with the angles in the injured and uninjured eyes is important, particularly in cases with subtle findings. Documented asymmetry supports the diagnosis.
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Ipsilateral anterior chamber depth may be increased following a contusion injury even if other signs of angle recession are absent. [36]
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Angle recession should be differentiated from cyclodialysis, which is the disinsertion of the ciliary body from its attachment to the scleral spur.
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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
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A strong association exists between traumatic hyphema and angle recession, [12] 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, 12]
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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
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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.
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Snellen visual acuity is typically uninvolved until the late stages of glaucoma.
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Formal visual field testing is of paramount importance in diagnosing and monitoring the disorder.
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.
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 [39] or cataract extraction, may also result in angle recession.
The most common types of blunt trauma are the following:
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Motor vehicle accidents (eg, airbag deployment, other facial trauma)
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Assaults
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Falls
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Military combat injuries
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Accidents (eg, industrial, farm, home, bungee cord injuries) [15]
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Other (eg, school accidents, natural disasters)
Complications
See the list below:
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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.
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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.
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Intraoperative complications of cataract surgery in traumatized eyes include the following:
Zonular dialysis
Vitreous loss
Intraocular hemorrhage
Suboptimal or 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°.
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Postoperative complications
IOP elevation
Inflammation
IOL malposition
Pupil capture
Intraocular hemorrhage
Glare
Monocular diplopia: Symptoms may result from iris abnormalities.
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Cataract extraction in eyes with known angle-recession deformities should be approached with caution.
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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
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Irregular widening of the visible ciliary body in a quadrant with angle recession.
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Angle recession. Note the marked posterior displacement of the iris, with a wide ciliary body band posterior to the scleral spur.
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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.
