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.
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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. Glaucoma medications should be implemented in the early stage of the condition. [44]
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.
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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. [44]
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. [23]
Atropine has been reported to reduce IOP in angle-recession glaucoma; therefore, cycloplegic agents may have a role in treatment. [44]
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).
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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.
Surgical Care
Surgical intervention in angle-recession glaucoma is usually indicated when maximally tolerated medical treatment has failed [44] 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.
Laser trabeculoplasty
Laser trabeculoplasty 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. [45]
IOP elevation may become worse in response to argon laser trabeculoplasty (ALT). [46]
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. [46] There are small case reports suggesting efficacy of SLT in treating some patients with angle recession glaucoma, however long term success rates and generalizability at this time are unknown. [47]
Alternative laser procedures
Nd:YAG laser trabeculopuncture (YLT) has been used with variable success. However, 1992 study demonstrated a 100% failure rate in eyes with 360° angle recession. [48] 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. [49]
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. [49] Serous retinal detachment has been reported as an early complication of trabeculectomy in angle-recession glaucoma. [50]
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. [51]
In the management of severe blunt trauma cases involving angle recession with dense vitreous hemorrhage and/or retinal detachment, combined trabeculectomy and pars plana vitrectomy has been reported with some successful outcomes. [52]
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. [53]
A 1993 study showed the superior results of trabeculectomy with antimetabolite over Molteno implantation in cases of posttraumatic angle-recession glaucoma. [54]
Implantation of a trabecular bypass stent in eyes with angle-recession glaucoma has been reported. [55]
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.
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.
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 to 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. [23]
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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.
