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Ophthalmic Pearls GLAUCOMA How to Diagnose and Treat Angle-Recession Glaucoma by sumalee boonyaleephan, md, and sarwat salim, md, facs edited by sharon fekrat, md, and ingrid u. scott, md, mph T raumatic glaucoma is a mul- 1 2 tifactorial group of disorders that results from closed- or open-globe injuries. Al- though different underlying mechanisms may be involved with the initial injury, the resulting optic neu- ropathy and visual field loss is second- A CLOSER LOOK. The anterior segment 3 ary to elevated IOP from reduction in exam shows anisocoria (1,2), with the aqueous outflow through the trabecu- left pupil showing mydriasis with seg- lar meshwork. Secondary glaucoma af- mental loss of pupillary ruff (2). On fur- ter trauma is more likely to occur with ther examination, widening of the ciliary a closed-globe injury, but it is often body band in the same eye was noted underdiagnosed because its onset may (3), indicating angle recession. be delayed and the history of eye injury may be remote or overlooked. dentation of the cornea forces posteri- Less often, a hyalinized membrane Angle recession is a common mani- or and lateral displacement of aqueous may cover the inner surface of the festation of blunt ocular trauma and humor, deepening the peripheral ante- trabecular meshwork. This membrane involves rupture of the ciliary body rior chamber and increasing the diam- may be continuous with Descemet’s face, resulting in a tear between the eter of the corneoscleral limbal ring. membrane and may extend peripher- longitudinal and circular fibers of These resultant shock waves traversing ally into the recessed angle and onto the ciliary muscle. Angle recession is the interior of the globe are responsible the anterior surface of the iris. The reported to occur in 20 to 94 percent for other anterior segment damage ac- membrane obstructs aqueous outflow, of eyes after blunt trauma and is often companying angle recession, such as causing an open-angle form of glauco- masked initially due to the presence of pupillary sphincter tears, iridodialysis, ma. In some cases, this membrane may concomitant hyphema, which results cyclodialysis and zonular tears. contract, resulting in angle-closure from shearing of the anterior ciliary The shearing forces to the drain- glaucoma. arteries. Approximately 5 to 20 percent age angle result in a tear between the of eyes with angle recession develop longitudinal and circular fibers of the Clinical Course and Signs angle-recession glaucoma. ciliary muscle. While the longitudinal As mentioned previously, 5 to 20 per- This brief review will discuss the muscle insertion at the scleral spur cent of eyes with angle recession de- pathophysiology and clinical course remains intact, the circular muscle is velop angle-recession glaucoma. Onset and signs of angle-recession glaucoma, displaced posteriorly along with the is extremely variable and may occur along with differential diagnosis and iris root and pars plicata. The resultant soon after the initial trauma or even treatment strategies. glaucoma is not due to angle recession years later, indicating possibly separate per se, but is secondary to initial trau- pathologic mechanisms. s a r w at s a l i m , m d Pathophysiology ma to the trabecular meshwork, with The risk of developing angle-reces- Blunt force to the globe causes an an- subsequent degenerative changes and sion glaucoma appears to be related terior to posterior axial compression scarring, which leads to obstruction of to the extent of angle recession. Angle with equatorial distension. Abrupt in- aqueous outflow. recession of more than 180 degrees is e y e n e t 41 Ophthalmic Pearls 4 5 Three Options for Treatment Medication. In the acute setting, treat- ment should be directed at lowering IOP and controlling inflammation. Topical steroids and cycloplegic agents are used to control inflammation and pain. Aqueous suppressants are preferred as initial IOP-lowering agents. Prostaglandin analogs have a theoretical benefit of bypassing the A CLUE. Iridodialysis (4) was the clue to look for other findings. Gonioscopy re- dysfunctional trabecular meshwork by vealed angle recession and patchy trabecular meshwork pigmentation (5). increasing uveoscleral outflow. Miot- ics should be avoided because they can deemed a considerable risk for second- fected and the nontraumatized eye or cause a paradoxical rise in IOP, pre- ary glaucoma, although glaucoma can in different quadrants of the involved sumably due to a reduction in uveo- develop when the area of recession is eye. Widening of the ciliary body band scleral outflow. smaller than this. may be present due to retrodisplace- Laser. Laser trabeculoplasty is not In one study, researchers found that ment of the iris root. Other signs effective in angle-recession glaucoma approximately 50 percent of patients include irregular and darker pigmen- due to distortion of the angle anatomy with traumatic glaucoma developed tation in the angle, whitening of the and trabecular meshwork scarring. An open-angle glaucoma in the unaffect- scleral spur due to visibly fractured iris alternative laser procedure, Nd:YAG ed, contralateral eye, suggesting that processes, or the presence of peripheral laser trabeculopuncture, has produced these patients may have an underlying anterior synechiae. variable success rates, with better re- genetic predisposition to developing Gonioscopy may aid in the diagno- sponses seen in cases where some tra- glaucoma, which may be accelerated by sis of other angle abnormalities from becular meshwork structure was intact a traumatic insult.1 trauma, such as iridodialysis or cyclo- on gonioscopy, permitting penetration IOP may rise immediately after the dialysis. It’s essential to note that, in into Schlemm’s canal with an increase injury, as a result of associated comor- some cases, the gonioscopic findings in aqueous outflow facility. bidities such as hyphema, iridocyclitis may become more difficult to recog- Surgery. Filtration surgery has a or pupillary block from ectopia lentis nize with the passage of time. lower success rate in angle-recession (with or without vitreous prolapse). Posterior segment examination will glaucoma than it does in primary In some cases, IOP may be low detect abnormalities that may also be open-angle glaucoma. The adjunctive secondary to decreased production present, and a dilated fundus exam use of antimetabolites can improve the of aqueous humor from associated should be performed after gonioscopy. success of trabeculectomy. Research- inflammation, a transient increase in ers have found greater IOP reduction aqueous outflow facility from disrup- Differential Diagnosis in cases where antimetabolites were tion of structures in the angle, or the After the trauma occurs, elevated IOP employed with trabeculectomy than in presence of a cyclodialysis cleft. may be secondary to obstruction of trabeculectomy alone or Molteno tube Anterior segment examination is the trabecular meshwork by red blood implantation alone.2 important. Once the acute inflamma- cells, inflammatory cells or pigmented Glaucoma drainage devices have tion and hyphema resolve, attention cells. Later, ghost-cell glaucoma may demonstrated some benefit, but their should be paid to the anterior cham- develop from long-standing vitreous success rates are lower in angle-reces- ber depth of the affected eye, which hemorrhage and a disrupted anterior sion glaucoma than with other types of may appear deeper. The meticulous hyaloid face or an open posterior cap- glaucomas. In eyes with limited visual physician will also look for other ab- sule. Chronic treatment with steroids potential, a cyclodestructive procedure normalities encountered with trauma, can lead to steroid-induced glaucoma. may be an alternative option. such as iris sphincter tears, mydriasis, Although the diagnosis of angle- iris atrophy, iridoschisis, iridodonesis, recession glaucoma is evident after Summary phacodonesis and a subluxated lens. careful gonioscopy and optic nerve ex- A patient who has experienced blunt Gonioscopy, a simple diagnostic amination, other differential diagnoses ocular trauma should receive a com- test, is essential for making the clinical for unilateral glaucoma should be con- prehensive eye exam to check for the diagnosis of angle recession. It is usu- sidered. These include—but are not presence of angle recession and other s a r w at s a l i m , m d ally deferred for four to six weeks after limited to—pseudoexfoliative glau- abnormalities. The risk of angle-re- the acute injury. When gonioscopy is coma, neovascular glaucoma, uveitic cession glaucoma correlates with the performed, asymmetry of the angle re- glaucoma, lens-particle glaucoma and extent and severity of angle recession. cess may be noticeable between the af- phacolytic glaucoma. In general, angle-recession glau- 42 o c t o b e r 2 0 1 0 coma is more difficult to control medi- From clerical staﬀ to cally and surgically than other types of glaucomas. Because angle-recession ophthalmic surgical nurses glaucoma can occur even many years after trauma, patients should receive Allied health staff members are a critical adequate counseling, and follow-up part of your practice’s patient care team. examinations should be performed regularly. 1 Tesluk, G. C. and G. L. Spaeth. Ophthal- mology 1985;92:904–911. 2 Mermoud, A. et al. Ophthalmology 1993;100:634–642. Dr. Boonyaleephan is a visiting research schol- ar in ophthalmology and Dr. Salim is associate professor of ophthalmology; both are at the University of Tennessee, Memphis. 6 7 8 COMPARISON. These eyes show angle recession in a Caucasian (6) and two African-American patients (7,8). The widening of the ciliary body band has Provide them with proper training resources to increase quality of care different colors (beige in 6, and bluish and efﬁciency. This will become even more important in the near future in 7 and 8). Recession can be subtle due to our nation’s aging population. To help, the Academy offers clinical (7) or more pronounced (6,8). education materials for all members of your team. Print, DVD and online products are available. Coding in Chicago For more information or to order, visit Attend Glaucoma Cod- www.aao.org/alliedhealth or call 415.561.8540. ing, event code “213.” It s a r w at s a l i m , m d walks you through suc- cessful glaucoma docu- mentation and coding and takes place Sunday, Oct. 17, from 2 to 3 p.m. e y e n e t 43
"How to Diagnose and Treat Angle Recession Glaucoma"