Angle Recession Glaucoma

Angle Recession Glaucoma
SYMPTOMS Usually asymptomatic. | Visual field loss in later stages. Blindness if left untreated.
With high IOP (usually >40mmHg), patient may experience eye pain, eye pressure, cloudy vision, nausea, or headaches
SIGNS Typically unilateral | Optic nerve damage (Notching, Rim tissue thinning, Cupping), RNFL thinning, Drance hemes, Peripapillary atrophy
Other ocular signs of trauma may be present, including corneal scars, iridodialysis, traumatic cataract, optic atrophy, etc.
WORK-UP Pupils | Slit lamp | IOP: Best to use GAT or ORA
Gonioscopy: Wide CBB (due to tear between the longitudinal and circular muscles) with scarring of the TM noted in 180-270 degrees of the angle. Possibly peripheral anterior synechiae. Comparison of gonioscopy findings with unaffected eye can be helpful in seeing the asymmetry, especially in subtle cases
Pachymetry: Thin corneas carry a higher risk of glaucoma
Visual field: Humphrey visual field threshold 24-2/30-2 is most common. Strong consideration should be given to now doing 24-2C as central and paracentral can be found in early glaucoma. Visual field threshold 10-2 should be done in later stages of glaucoma
Anterior segment OCT | OCT analysis of the optic nerve, RNFL, GCC: RNFL and GCC thinning (GCC thinning typically precedes RNFL thinning) | OCT-Angiography (Assess the radial peripapillary capillary plexus and superficial capillary plexus)
Dilated fundus exam | Optic nerve photos | Corneal hysteresis: Low hysteresis carries a higher risk of glaucoma | VEP/Pattern ERG: To assess ganglion cell health | Ultrasound biomicroscopy
TREATMENT Angle recession with normal IOPs and healthy optic nerves: Treat as a glaucoma suspect. No treatment needed
Angle recession with elevated IOPs and healthy optic nerves: Begin glaucoma treatment
Angle recession with secondary open angle glaucoma: Begin glaucoma treatment
Due to the aggressive nature of angle recession glaucoma, begin with a combo drop: Cosopt (1gtt BID), Combigan (1gtt BID), or Simbrinza (1gtt TID).
Prostaglandins (Lumigan, Latanoprost, Travatan, Zioptan, Vyzulta) or Rhopressa should be considered as the next adjunct drop dosed at 1gtt QHS
Topical CAIs and alpha-2-agonists are to be used 1gtt TID if utilized as stand-alone therapy or 1gtt BID as adjunct therapy
Apraclonidine and Diamox can be given in-office or on a short term basis to quickly lower IOPs but should not be used long-term
Pilocarpine should be avoided in these patients | Always keep in mind the contraindications and side effects before prescribing these medications
SLT is not very effective in this type of glaucoma
If using more than 2 different types of glaucoma drops in order to manage patient, co-management with a glaucoma specialist should be considered. If using more than 3 different types of glaucoma, refer to a glaucoma specialist for co-management.
Patients with advanced, severe, or end stage glaucoma should be co-managed with a glaucoma specialist as further intervention such as blebs, MIGs, or shunts may be needed (Filtration surgeries have a lower success rate than in POAG)
*Angle recession glaucoma is overall difficult to treat and most likely will need to be referred or co-managed with a glaucoma specialist*
FOLLOW-UP Angle recession with normal IOPs and healthy optic nerves: Monitor every 6 months to 1 year
Angle recession with elevated IOPs and healthy optic nerves: Begin treatment. Follow up in 2-4 weeks after initiation of treatment to assess IOP with subsequent follow-ups of every 3-4 months for glaucoma evaluation and repeat testing
Angle recession with secondary open angle glaucoma: Begin treatment. Follow up in 2-4 weeks after initiation of treatment to assess IOP with subsequent follow-ups of every 3-4 months for glaucoma evaluation and repeat testing
ADDITIONAL LAB | TESTS None, although lab tests such as orbital CT may be ordered for other ocular complications associated with trauma
ETIOLOGY Hydraulic forces in aqueous caused by trauma can lead to damage of the ciliary body band and trabecular meshwork.
Direct damage to the trabecular meshwork reduces outflow. White blood cells clogging the trabecular meshwork and scarring of the trabecular meshwork further reduce outflow
DIFFERENTIAL DX Steroid response glaucoma, Pseudoexfoliation glaucoma, Pigment dispersion glaucoma, Uveitis-Glaucoma-Hyphema (UGH) syndrome
NOTES Angle recession is a type of secondary open angle glaucoma
Gonioscopy should not be done immediately after ocular trauma (typically done 4-6 months after ocular trauma)
Angle recession glaucoma is typically seen months to years later following the initial trauma
The majority of patients with a history of traumatic hyphema will have some angle recession
50% of eyes with angle recession glaucoma will develop glaucoma in the other eye
Posted in Ocular Conditions, Trauma