Angle Recession Glaucoma

Overview

Angle recession occurs as a result of blunt ocular trauma. The force of the trauma displaces aqueous posteriorly and laterally, exerting a force on the iris root, causing a separation of the longitudinal and circular fibres of the cilliary body.

Angle recession due to blunt ocular trauma has been reported to be associated with secondary open angle glaucoma in 5-20% of cases with a higher risk associated with angle recession spanning more than 180 degrees.

As discussed within the Gonioscopy page of this resource, angle recession is characterised by a focal widening of the ciliary body band on gonioscopy, and typically also increased trabecular meshwork pigmentation.

In the acute stages, traumatic forces may also cause damage to the trabecular meshwork, impeding aqueous outflow and leading to a subsequent increase in intraocular pressure. These same forces may also damage the anterior and/or posterior ciliary arteries, leading to hyphema (blood in the anterior chamber). The drainage of the red blood and inflammatory cells through the trabecular meshwork may further increase intraocular pressure.

Scarring and degeneration of the trabecular meshwork may cause increased intraocular pressure and subsequent glaucoma, even decades after the initial trauma.

Case Examples

  • Case 1: Ocular hypertension associated with angle recession

    A 34 year old male with history of blunt trauma to his left eye 8 years ago. His visual acuity is 6/4.8- (20/16-) in each eye. His intraocular pressures were 21mmHg in the right eye and 27mmHg in the left in the context of thicker than average corneas (588µm OD and 590µm OS).

    Goniophoto (left eye, inferior angle)

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    Goniophoto (left eye, inferior angle)

    Gonioscopy shows angle recession inferiorly in the left eye. All other quadrants showed angles open to the ciliary body band with no other anomalies noted.

    Fundus photograph and red-free image (left eye)

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    Fundus photograph and red-free image (left eye)

    Fundus photos show average sized discs with shallow cupping and a healthy neuroretinal rim. The red-free image shows normal, healthy retinal striations.

    Stereophoto (left optic disc)

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    Stereophoto (left optic disc)

    The stereophoto of the left optic disc shows an intact neuroretinal rim with no focal or generalised thinning apparent.

    Cirrus RNFL Analysis

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    Cirrus RNFL Analysis

    The TSNIT curve shows the RNFL thicknesses to be relatively symmetrical between the two eyes. There are no areas of thinning identified on the deviation map, and a comparison of the quadrant thicknesses between the two eyes confirms the symmetry.

    Cirrus Ganglion Cell Analysis

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    Cirrus Ganglion Cell Analysis

    GCA shows no areas of thinning on the deviation map and comparison of the sector thicknesses confirms relative symmetry between the eyes.

    24-2 SITA-Faster visual field analysis

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    24-2 SITA-Faster visual field analysis

    The 24-2 field analysis shows no defects.

    Both structural and functional findings confirm no glaucomatous damage at this time, however this patient was referred to an ophthalmologist for consideration of treatment of ocular hypertension secondary to angle recession.

  • Case 2: Angle recession glaucoma

    A 56 year old Caucasian male with a history of trauma to the right eye 16 years ago. 6 weeks after the trauma he underwent right cataract surgery. Prior to surgery, the patient had high myopia in both eyes. He reports no family history of glaucoma. His intraocular pressures were 22mmHg (OD) and 15mmHg (OS) in the context of average pachymetry values (568µm OD, 553µm OS).

    Goniophotos (right eye)

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    Goniophotos (right eye)

    1. Goniophoto of the inferior angle
    2. Goniophoto of the superior angle

    Gonioscopy shows angle recession (blue arrows) in the inferior and superior angle. There is also a focal band of peripheral anterior synechiae in the superior angle. A superior iridectomy can also be seen (green arrow).

    Fundus photograph and red-free image (right eye)

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    Fundus photograph and red-free image (right eye)

    Retinal photos show an average sized disc with peripapillary atrophy (PPA). The superior and inferotemporal neuroretinal rim appears thin. Pigmentary changes are also evident at the posterior pole.

    Fundus photograph and red-free image (left eye)

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    Fundus photograph and red-free image (left eye)

    Retinal photos show an average sized disc with peripapillary atrophy. The neuroretinal rim and RNFL both appear healthy. There are also mild pigmentary changes at the macula.

    Stereophoto of the right optic disc

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    Stereophoto of the right optic disc

    Please view this image using 15 prism dioptres base out.

    Both the superior and inferotemporal neuroretinal rim show thinning.

    Stereophoto of the right optic disc

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    Stereophoto of the right optic disc

    Please view this image using 15 prism dioptres base out.

    The neuroretinal rim appears intact in the left eye.

    Cirrus RNFL analysis

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    Cirrus RNFL analysis

    OCT shows inferotemporal RNFL loss in the right eye, most evident on the RNFL heat map.

    In the left eye, the OCT flags superior and inferior RNFL loss on the deviation map. However, upon closer inspection, the TSNIT curve and heat map shows a split bundle superiorly and a temporal shift inferiorly. This indicates that this apparent thinning is likely due to a physiological distribution of the RNFL rather than an actual loss.

    Cirrus Ganglion Cell Analysis (GCA)

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    Cirrus Ganglion Cell Analysis (GCA)

    GCA shows inferotemporal thinning in the right eye that respects the horizontal raphe. The GC-IPL thickness in the left eye is within the normative database.

    Matrix 24-2 FDT Threshold visual field analysis

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    Matrix 24-2 FDT Threshold visual field analysis

    These results show possible superonasal clusters of reduced sensitivity which may correspond with the structural findings in the right eye.

    Based on the clinical picture, this patient was diagnosed with angle recession glaucoma in the right eye and referred to an ophthalmologist for management.

References

Kaufman JH, Tolpin DW. Glaucoma after traumatic angle recession a ten-year prospective study. Am J Ophthalmol. 1974;78
(4):648–654.

Ng, D.SC., Ching, R.HY. & Chan, C.WN. Angle-recession glaucoma: long-term clinical outcomes over a 10-year period in traumatic microhyphema. Int Ophthalmol 35, 107–113 (2015)

Senthil, S. Dangeti, D. Battula, M. Rao, HL. Garudadri, C. (2021): Trabeculectomy with Mitomycin-C in Post-Traumatic Angle Recession
Glaucoma in Phakic Eyes With no Prior Intraocular Intervention, Seminars in Ophthalmology