Angle Recession Glaucoma

• Angle Recession Glaucoma Overview
• Angle Recession Glaucoma Causes
• Angle Recession Glaucoma Symptoms
• When to Seek Medical Care
• Questions to Ask the Doctor
• Exams and Tests
• Angle Recession Glaucoma Treatment
• Self-Care at Home
• Medical Treatment
• Medications
• Surgery
• Next Steps
• Follow-up
• Prevention
• Outlook
• Support Groups and Counseling
• For More Information
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• Authors and Editors

Angle Recession Glaucoma Overview

Traumatic glaucoma refers to a group of ocular disorders that occur after the eye undergoes trauma. Following this trauma, different mechanisms can cause an abnormal elevation of pressure inside the eye, called intraocular pressure (IOP), and increase the risk of damage to the optic nerve.  

• Eye pressure is measured in millimeters of mercury (mm Hg). Normal eye pressure typically ranges from 10-20 mm Hg. When your pressure is higher than 20 mm Hg, you may be at an increased risk for developing glaucoma.
  
  
• High pressure inside the eye is caused by an imbalance in the production and drainage of fluid in the eye (aqueous humor). The channels that normally drain the fluid from inside the eye do not function properly or are blocked. More fluid is continually being produced but cannot be drained because of the improperly functioning or blocked drainage channels.  This results in an increased amount of fluid inside the eye, thus raising the pressure.
  
  
• Another way to think of high pressure inside the eye is to imagine a water balloon. The more water that is put into the balloon, the higher the pressure inside the balloon. The same situation exists with too much fluid inside the eye. The more fluid, the higher the pressure. Also, just like a water balloon can burst if too much water is put into it, the optic nerve in the eye can be damaged by too high of a pressure.
  
  
• Glaucoma is usually high pressure inside the eye that damages the optic nerve and can result in permanent vision loss. Not all 3 criteria (that is, high pressure inside the eye, optic nerve damage, and vision loss) are required to diagnose glaucoma; however, a diagnosis of glaucoma is often determined when all 3 criteria are present.

Angle recession glaucoma is a type of traumatic glaucoma. It is classified as a traumatic, secondary open-angle glaucoma. This means that the open-angle glaucoma occurs due to a specific cause, in this case a traumatic event. Angle recession, with or without a diagnosis of glaucoma, commonly results after the eye experiences blunt trauma.

Although angle recession glaucoma is uncommon, it may not be readily diagnosed because the onset of symptoms is often delayed. The eye injury might have occurred a long time ago and, perhaps, has even been forgotten by the person.

Of those eyes with angle recession, very few (reportedly 0-20%) develop glaucoma. In those that do develop glaucoma, the onset is extremely variable, ranging from immediately following the trauma to months or even many years later.

The risk of eventual progression to glaucoma is generally accepted to be proportionate to the extent of the angle recession, although the presence of angle recession alone is not a good predictor for the occurrence of glaucoma.

• Glaucoma following an angle recession that involves less than 180° of the iris is very unusual.
  
  
• Recessions involving more than 180° of the iris are associated with a 4-9% incidence of glaucoma.
  
  
• Eyes with an angle recession involving more than 240° of the iris appear to be at the highest risk for glaucoma.

In the United States, over 1 million Americans experience eye injuries each year. Blunt eye injuries are estimated to account for over 60% of all episodes of eye trauma. Although injuries often occur to only one eye, the incidence rate of trauma to both eyes is as high as 27%.

• In 1988, a study of adults in New England yielded an annual rate of 9.75 eye injuries per 1000 people, based on a self-reported history.
  
  
• In 1990, an estimated hospitalization rate for children with eye trauma was reportedly 15.2 eye injuries per 100,000 children per year.
  
  
• Work-related injuries have been reported as 13-18% of total eye trauma cases.
  
  
• Injuries at home account for 27-31% of eye trauma cases, followed by assault (11-37%), recreation (approximately 25%), travel (approximately 5%), and miscellaneous (eg, school, unknown; <5%).

Angle recession is one of the most common complications after eye trauma. The exact incidence of angle recession in the United States has not been reported, but it has been described in 20-94% of eyes that have experienced blunt trauma. 

• Angle recession following traumatic hyphema (bleeding into the anterior chamber of the eye) occurs in 71-100% of cases.
  
  
• A 1987 study involving routine examination of asymptomatic (that is, no symptoms) boxers found angle recession in 19%, with 8% having angle recession in both eyes.

Worldwide, the incidence of eye trauma is similar to that found in the United States.

• A study of Australian adults older than 40 years yielded a lifetime cumulative rate of eye injury of 21.1%. Among men, those in rural areas had higher rates than those in urban areas (42.1% vs 30.5%). In contrast to US data, workplace injuries predominated at 60%, with home injuries closer to agreement with US figures at 24%.
  
  
• The Israeli Ocular Injuries Study reported in 1988 that injuries occurring at home were the most frequent type of eye trauma in Israel.
  
  
• A 1995 study of eye trauma among Nigerians reported the rate of home injuries at 26.4%. This study identified women and children at the greatest risk of sustaining eye trauma during domestic activities.
  
  
• A 1996 report described a predominance of home injuries in Scotland.

As in the United States, the exact incidence of angle recession in other countries is unclear. Most reports verify that contusional injuries (direct blows to the eye) represent most eye trauma cases, but rates of angle recession and/or traumatic glaucoma are not well documented.

• One survey published in 1994 based on the results from gonioscopic examinations (see Exams and Tests) of individuals older than 40 years in a community in South Africa reported a cumulative prevalence of angle recession of 14.6%.
  
  
• In this study, it was found that of eyes with angle recession involving all 360° of the iris, only 8% had glaucoma, and the overall prevalence of glaucoma of eyes with any degree of angle recession was 5.5%.

Eye injury is a relatively common occurrence in people who are admitted to the hospital or present to the emergency department with major head trauma.

• In 1996, a study found that an annual cumulative incidence of serious eye trauma necessitating hospital admission was approximately 8 per 100,000 cases. Of those cases, approximately 13% had a poor visual outcome; 10.7% had a blinding outcome.
  
  
• In 1999, a study reported eye injuries in 55% of all facial injuries and in 16% of all major trauma cases.

Because angle recession glaucoma can have its onset years after the traumatic episode, estimating the resultant visual disability is difficult. Published data of visual outcomes following eye trauma usually only describe short-term results. The long-term incidence of significant vision loss or blindness from posttraumatic glaucoma has not been reported.

Angle recession glaucoma appears to affect all races equally. In general, African Americans may be at an increased risk for all types of glaucoma, particularly primary open-angle glaucoma (POAG).  

• Because of the possible relationship of POAG with angle recession glaucoma, African Americans theoretically may be at an increased risk of glaucoma following eye trauma.
  
  
• One urban study published in 1991 found that, at a Los Angeles inner city hospital, African Americans experienced eye injuries more than twice as frequently as Hispanics. However, a comparison of rates of progression to angle recession glaucoma among different races has not yet been reported.

Among men and women, eye trauma occurs more often to men, outnumbering women by a ratio of 4 to 1. Therefore, presumably, angle recession and angle recession glaucoma develop most frequently in men.  

• Women appear to be at a greater risk of sustaining eye injuries at home.
  
  
• Among children, eye injuries occur more frequently in boys than in girls.

The risk of angle recession as a person gets older has not been formally described.

• Because the onset of symptoms is often delayed following a blunt eye injury, angle recession glaucoma is not usually diagnosed until middle to late adulthood. It may even be misidentified as POAG, since angle abnormalities may not be readily evident on examination and often appear late in the disease course. A distant or even forgotten history of eye trauma, particularly common among elderly persons, may result in the condition being overlooked.
  
  
• Among adults, the risk of injury appears to decline steeply with advancing age. Studies of urban populations have indicated that elderly persons sustained only 1.6% of eye trauma, and, for persons older than 65 years, eye injuries were most often due to a fall.
  
  
• Angle recession glaucoma has been described in childhood, but eye trauma generally occurs during young adulthood. The annual incidence of pediatric eye injuries has been reported at 15 per 100,000 children.