Angle recession glaucoma

2. INTRODUCTION
• Secondary open-angle glaucoma
• Presents with an elevated intraocular pressure up to
years after onset of blunt trauma
• This condition may be underdiagnosed because
onset is often delayed and because a history of eye
injury may be distant or forgotten
• Clinically, patients with angle recession glaucoma are
usually detected during a routine eye examination
later in life

3. ANATOMY

5. • Angle recession refers to a tear between the circular
and longitudinal fibers of the ciliary body.
• Cyclodialysis is defined as a detachment of the ciliary
body from its insertion at the scleral spur.
• Iridodialysis is separation of the iris root from its
attachment to the anterior ciliary body.
• By comparison, iridoschisis refers to splitting of
layers of iris stroma.
• All of these conditions are sequelae of blunt ocular
trauma, and any of these conditions may coexist.
• Iridodialysis and cyclodialysis occur at higher blunt
impact energies compared with the relatively lower
thresholds resulting in angle recession.

8. HISTORY
• Angle recession was first described by Collins in
1892 [1]
• The association between trauma and unilateral
glaucoma was made by D'Ombrain in 1949 [2]
• The pathological entity of angle recession and the
clinical phenomenon of unilateral chronic glaucoma
were linked by Wolff and Zimmerman in 1962.[3]
1)Collins ET. On the pathological examination of three eyes lost from concussion. Trans Ophthalmol Soc UK.
1892;12:180–186.
2) D’Ombrain. Traumatic or concussion chronic glaucoma. Br J Ophthalmol. 1949;33:395–400
3)Wolff SM, Zimmerman LE. Chronic secondary glaucoma. Association with retrodisplacement of iris root and
deepening of the anterior chamber angle secondary to contusion. Am J Ophthalmol. 1962. 84:547-63.

9. ETIOLOGY
• Any cause of nonpenetrating ocular trauma can result
in angle-recession glaucoma.
• The most common types of blunt trauma are the
following:
• Sports injuries (eg, boxing, paintball, airsoft gun toys)
• Motor vehicle accidents (eg, airbag deployment, other
facial trauma)
• Assaults
• Falls
• Military combat injuries
• Accidents (eg, industrial, farm, home, bungee cord
injuries
• Ocular surgery, such as penetrating keratoplastyor
cataract extraction, may also result in angle recession

10. EPIDEMIOLOGY
• The reported frequency of angle recession as a
complication of blunt trauma is 20-94%.
• Angle recession after traumatic hyphema occurs in
71-100% of cases.
• Of eyes with identifiable angle recession, 1-20%
develop glaucoma
• Interestingly, up to 50% of patients whose angle
recession progresses to glaucomatous optic
neuropathy will develop glaucoma in the fellow
uninjured eye.*
* Tesluk GC, Spaeth GL. The occurrence of primary open-angle glaucoma in the
fellow eye of patients with unilateral angle-cleavage glaucoma. Ophthalmology.
1985;92:904-911.

11. • Glaucoma after angle recession of less than
180° is unusual;
• Recessions greater than 180° are associated
with a 4-9% incidence of glaucoma.
• Eyes with angle recession of greater than
240° appear to be at the highest risk of
chronic glaucoma
• Other risk factors for progression to glaucoma
after ocular contusion include chronic
elevation of intraocular pressure, poor initial
visual acuity, advancing age, lens injury, and
hyphema.

12. • The elevation of intraocular pressure from angle
recession demonstrates a bimodal pattern with
glaucoma occurring either within the first year or
after 10 years as described by Blanton
• No known racial predilection exists.
• No gender predilection for angle-recession glaucoma
has been reported.
• A strong predominance of eye trauma exists in men,
with a male-to-female ratio of 4:1. Therefore, it may
be assumed that angle recession and angle-recession
glaucoma occur most frequently in men.

13. PATHOGENESIS
• The mechanism of glaucoma associated with angle
recession appears to involve 5 processes.
• First, blunt force delivered to the globe initiates an
anterior to posterior axial compression with
equatorial expansion.
• Sudden indentation of the cornea may be a key
factor in angle trauma, creating a hydrodynamic
effect by which aqueous is rapidly forced laterally,
deepening the peripheral anterior chamber and
increasing the diameter of the corneoscleral limbal
ring

14. • Second, this transient anatomic deformity results in a
shearing force applied to the angle structures,
causing disruption at the weakest points if the force
applied exceeds the elasticity of the tissues.

15. • Third, the ciliary body is torn in a manner such that
the longitudinal muscle remains attached to its
insertion at the scleral spur, while the circular
muscle, with the pars plicata and the iris root, is
displaced posteriorly.
• During this process, shearing of the anastomotic
branches of the anterior ciliary arteries can occur,
resulting in a hyphema.
• The anterior chamber typically becomes abnormally
deep in the meridians of recessed angle due to
posterior deviation of the relaxed iris-lens
diaphragm.

16. • Fourth, in some cases, angle recession progresses to
glaucoma.
• The contusional deformity, when extensive, may
result in trabecular dysfunction, which may lead to
early or delayed loss of outflow facility and elevation
of IOP.
• Fifth, chronic elevation of IOP leads to optic
neuropathy characterized by progressive optic
cupping and visual field loss.

17. • Two other proposed mechanisms to explain the
elevated pressures are
• Loss of tension of ciliary muscle on the scleral spur
thus narrowing Schlemm’s canal [1]
• A hyaline membrane has been reported to grow
across the trabecular meshwork which may be
another mechanism to explain decreased aqueous
outflow[2].
1)Herschler J. Trabecular damage due to blunt anterior segment injury and its
relationship to traumatic glaucoma. Trans Am Acad Ophthalmol Otolaryngol
.1977;83:239
2)Jensen OA. Contusion angle recession, a histopathological study of a Danish
material. Ophthalmol. 1968;46:1207–1212

18. CLINICAL FEATURES
• 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.
• A unilateral cataract in a young or middle-aged
adult should raise the suspicion of remote
trauma, even when the history is negative
• Like in patients with other forms of glaucoma,
may present with no specific eye or visual
complaints.

19. • Snellen visual acuity is typically uninvolved until
the late stages of glaucoma.
• Angle recession is typically diagnosed by means
of gonioscopy.
• Typically, an irregularly wide ciliary body band is
visible with retroplacement of the iris root.
• More likely to occur in the superotemporal
quadrant.
• Comparison with the angles in the injured and
uninjured eyes is important, particularly in cases
with subtle findings. Documented asymmetry
supports the diagnosis.
• A localized deepening of the anterior chamber is
frequent

20. 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

21. RETINAL DIALYSIS
ZONULAR
WEAKNESS
TM TEAR
CYCLODIALYSIS
ANGLE
RECESSION
IRIDODIALYSIS
SPHINCTER
TEAR

22. • 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

23. MANAGEMENT
• Response to treatment of recession-angle glaucoma
varies widely and is related chiefly to the nature and
extent of the changes in the angle.
• The more extensively the angle is damaged, the less
responsive the glaucoma tends to be to treatment

24. • 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.

25. • 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).

26. • Argon laser trabeculoplasty has yielded rather
unsatisfactory results and fails to lower the IOP long
term in this group of patient
• Selective laser trabeculoplasty has not been formally
studied but is likely to also be ineffective.
• An alternative laser procedure, Nd:YAG laser
trabeculopuncture, in which an energy of 1.0 to 2.5
mJ is applied to the meshwork in a manner similar to
argon laser trabeculoplasty, has been reported to
offer significant advantages over trabeculoplasty in
the treatment of angle- recession glaucoma

27. • When maximally tolerated medical therapy fails to
control the IOP adequately, filtering surgery may be
indicated.
• Mermoud et al compared standard trabeculectomy,
trabeculectomy with antimetabolites, and the
implantation of a Molteno device (IOP Ophthalmics)
in the eyes of patients with uncontrolled ARG
• Trabeculectomy with antimetabolites was the most
effective at controlling the IOP with the fewest
postoperative antiglaucoma medications, but the
rate of bleb-related infection was also highest in this
study group
Mermoud A, Salmon JF, Barron A, et al. Surgical management of post-traumatic angle recession glaucoma.
Ophthalmology. 1993;100:634-642.

28. TAKE HOME MESSAGE
• Glaucomatous optic neuropathy can be a devastating
consequence of angle-recession blunt injury.
• Early diagnosis and aggressive intervention to lower
the IOP are of the utmost importance.
• Physicians must educate patients on their injury so that
they understand their lifetime risk of developing
glaucoma.
• Careful lifelong monitoring of their IOP and
examinations of their optic nerves is recommended
for patients who experience angle recession, because
glaucoma is usually an asymptomatic disease