The document summarizes several studies on angle recession glaucoma following blunt ocular trauma. The first study found that ultrasound biomicroscopy is useful for detecting angle pathology when the media is hazy. Surgical treatment resulted in more stable and normal intraocular pressure compared to medical treatment alone. The second study in Bangladesh found that conservative treatment controlled intraocular pressure in most cases, while a small percentage required surgery. The third study found that trabeculectomy with antimetabolic drugs was most effective for uncontrolled angle recession glaucoma, but carried a higher risk of late bleb infection.

2. Journal-1
Glaucoma following blunt
trauma: Clinical Study
Purvi R. Bhagat1, Priyanka Gupta2, Nitesh Agrawal3, Mariam N.
Mansuri4
Journal of Evolution of Medical and Dental Sciences;
March 17, 2014

3. • AIMS:
To study the treatment modalities and long term follow up of patients suffering from
glaucoma developing after blunt trauma.
• MATERIALS AND METHODS:
Prospective study over one year in 75 eyes, newly diagnosed or referred with post
traumatic glaucoma.
All cases underwent a detailed eye examination.
Treatment (medical/surgical) was individualized in each case and instituted to the
patients.

4. RESULT:
• IOP at present:
16% patients presented with IOP in the normal range,
38 (50.66%) patients had IOP in the range of 21-30 mm Hg, whereas 16 (21.33%)
patients had IOP more than 40 mm Hg.
• Within 1 week of instituting treatment,
41 (54.66%) had IOP ≤ 20 mm Hg and
only 3 patients had IOP more than 30 mm Hg.
However, 70 (93.33%) patients had IOP ≤ 20 mm Hg by the end of 6 months and all
the patients were in this range after 6 months.

5. • On slit lamp examination,
corneal edema, traumatic mydriasis and sphincter tears were seen in 32
patients each.
12 patients had hyphema and
19 patients had lens dislocated either into vitreous or into the anterior
chamber.
Iridodialysis was seen in 5 patients.
• Disc changes could be assessed by ophthalmoscopy in 37 (49.33%)
patients at presentation.
Of these, 21 (56.75%) patients had a cup-disc ratio of less than 0.5 whereas
remaining 12 had a cup- disc ratio of more than or equal to 0.5.
5 patients demonstrated unhealthy neuroretinal rim, nasalized blood vessels,
lamellar dot sign, deep cup.

6. • Gonioscopy could be done only in 38 patients.
26 (68.42%) had open angles and
5 patients had closed angles.
17 (44.73%) had angle recession, and
4 patients of these 17 had angle recession ≥ 180°.
Other findings included iridodialysis (2 patients), cyclodialysis (1 patient), blood
clots in the angle, heavy pigmentation of trabecular meshwork, convex iris and
haptic of PCIOL lodged in the angle.
• UBM (ultrabiomicroscopy) could be performed in 71 patients. It
detected –
angle recession in 23 patients,
lens subluxation or dislocation in 20 patients,
hyphema in 6 patients,
iridodialysis in 4 patients.

7. • 16 (21.33%) patients responded to a single drug regimen,
• 12 patients required more than 2 drugs,
• 7 patients underwent Trabeculectomy with Mitomycin C.
• Other modalities of management included
paracentesis (2 patients),
cataract extraction with IOL implantation (8 patients),
lensectomy (4 patients),
vitrectomy with lensectomy (18 patients),
peripheral iridectomy (6 patients); and
cataract extraction with IOL implantation with trabeculectomy with
Mitomycin C (1 patient).

8. TAKE HOME MESSAGE:
• UBM is a good adjunct to gonioscopy where media haze is present.
• Visual outcomes were found to be better in patients who underwent
surgery either in the form of cataract extraction and IOL implantation
or antiglaucoma surgery.
• Moreover the patients treated surgically displayed a consistently
stable, normal range IOP.
• In traumatic glaucoma, antiglaucoma medication should be used
early and surgery should be carried out when medical treatment does
not reduce the elevated IOP.

9. Journal- 2
Angle recession Glaucoma:
Management outcomes in
Chittagong, Bangladesh
Dr. M. A. Karim, Dr. Shams Mohammad Noman, Dr. Shailendra Sugrim
Horizon, Volume 4, September 2009

10. • PURPOSE:
To document & describe the patterns of outcomes & management
approaches to patients diagnosed with angle recession glaucoma presenting
at the GLAUCOMA DEPARTMENT, CHITTAGONG EYE INFIRMARY & TRAINING
COMPLEX, BANGLADESH.
• DESIGN:
Hospital based prospective observational case series review.

11. • PARTICIPANTS:
25 patients; over a 1 year period from November 1st
2007 to October 31st
2008.
• METHOD:
patient particulars, history & mechanism of trauma were recorded.
Ophthalmic examination details (including gonioscopy, intraocular pressure &
fundoscopy) & management given were documented.
Similar relevant details were recorded for three follow up periods on
patients, extending over a total period of 9 months.

12. RESULTS:
• 25 patients were included. Of these, 14 (56%) were newly diagnosed cases &
11 (44%) were previously diagnosed patients.
• 22 (88%) of the patients were male & 3 (12%) were female.
• With regards of the age group of the patients, 8 (32%) were in the 0 – 19
years category & 5 (20%) in the 60- 79 years category. In all age group
categories male were significantly more than females.
• All patients had an angle cleavage of more than 180 degrees, with 68% having
a recession of 360 degrees. 56% had a history of hyphaema.

13. • In 88% patients the IOP was controlled & kept at a stable level (< 21 mmHg)
over the follow up periods & in 12% the IOP was not controlled.
• 91% were controlled by conservative treatment.
• The remaining 9% had surgical intervention.
• Patients with uncontrolled IOP (12%) were advised for filtration surgery.
• The mean IOP at the time of diagnosis was 29.8 +/- 9.7 mm Hg (Range 14- 50
mm Hg). The mean IOP at last follow up was 18.4 +/- 8.4 mm Hg (range 10 –
50 mm Hg).

14. Journal- 3
Surgical Management of Post-
traumatic Angle Recession
Glaucoma
Ophthalmology Department, Groote Schuur Hospital & University of
Cape Town.
American Academy of Ophthalmology, May 1993

15. • PURPOSE:
The purpose of this study is to compare the results of three different
drainage procedures (trabeculectomy, Molteno single-plate implantation,
and trabeculectomy combined with antimetabolite) performed for
uncontrolled post-traumatic angle recession glaucoma.
• METHODS:
A retrospective analysis was undertaken of 87 drainage procedures
performed on 65 patients over an 8-year period.
Of those treated with antimetabolite, 11 received postoperative
subconjunctival injections of 5-fluorouracil and 9 received an intraoperative
application of 0.02% mitomycin C to the trabeculectomy site.

16. RESULT:
• In the group undergoing trabeculectomy with antimetabolite
therapy, the intraocular pressure (IOP) drop was significantly greater,
the percentage of successful cases at 3 and 6 months postoperatively
was significantly higher, and the number of postoperative glaucoma
medications use was significantly lower than the other two groups.
• No statistically significant differences were found between the groups
undergoing trabeculectomy without antimetabolite therapy and
Molteno implantation.

17. TAKE HOME MESSAGE:
• In medically uncontrolled post-traumatic angle recession glaucoma,
trabeculectomy with antimetabolite therapy is the most effective
surgical procedure.
• However, late bleb infection is a significant risk.

18. Review article on
ANGLE RECESSION
GLAUCOMA
Journal Of Vision Sciences, May – Aug 2015

19. • Angle recession glaucoma is a chronic, unilateral secondary OAG.
• Angle recession, with or without glaucoma, is a common sequel of
blunt ocular trauma
• characterized by a variable degree of tear between the circular and
the longitudinal fibers of the ciliary muscle.
• Angle recession glaucoma is most likely diagnosed in mid or late
adulthood due to the potential delay or late onset after a blunt
injury.

20. CAUSES
• Most common causes –
sports or other recreational accidents (55.6%; 114 of 205) and
assault (65%; 57 of 87).
• Less common causes –
automobile or industrial accidents,
projectiles from toy guns or slingshots, and
other leisure activities.
• Very rarely ocular surgical procedure (cataract surgery and
penetrating keratoplasty).

21. CLASSIFICATION
• A classification of angle recession with regard to the depth of ciliary
muscle tears has been proposed by Howard et al.
In shallow tears, separation of the processes of the uveal meshwork is
present. The ciliary body band appears darker and wider, whereas the scleral
spur appears whiter than the opposite eye.
Moderate tears – a definite cleft into the fibers of the ciliary muscle, and the
angle appears deeper than that of the opposite eye.
Deep tears – a fissure in the ciliary body, and the apex of the fissure cannot
be seen gonioscopically.

22. PATHOPHYSIOLOGY
BLUNT FORCE
Anterior- posterior axial compression
& Equatorial expansion
indentation of cornea
Aqueous is forced laterally
Deepening of peripheral anterior chamber & Raised IOP
Increase in diameter of corneoscleral limbal ring
disruption at the weakest points

23. In the presence of more significant injury,
atrophy of the inner circular muscles of the ciliary body
obliteration of the intertrabecular spaces and Schlemm’s canal
Growth of hyaline membrane across the trabecular meshwork
decreased aqueous outflow
Elevated IOP

24. WORK UP
• Gonioscopy : It is usually deferred for 4-6 weeks after the acute injury.
• Imaging studies: Zonular deficiency and angle recession are the most common
UBM findings in a closed-globe injury.
• Anterior segment optical coherence tomography (AS-OCT): valuable
tool in identifying angle pathology in post traumatic eyes.
• Visual field test: the most important adjunctive diagnostic modality in
detecting and following up the disorder.

25. MEDICAL MANAGEMENT
• Most preferred medical treatment –
Topical aqueous suppressants. These include beta-antagonists,
alpha- agonists, and carbonic anhydrase inhibitors.
• Cycloplegic agents may have a role in treatment

26. LASER TREATMENT
• Argon laser trabeculoplasty (ALT): beneficial In eyes with <180° of
angle recession.

27. SURGICAL MANAGEMENT
• Trabeculectomy: in eyes with angle recession is associated with decreased
post-operative reduction in IOP, increased rates of bleb fibrosis and bleb failure,
and increased dependence on post-operative medical treatment of glaucoma.
• The adjunctive use of antimetabolites, particularly mitomycin C, can
improve the success of trabeculectomy.
• Artificial drainage devices (tube shunt devices)

28. TAKE HOME MESSAGE
• Early diagnosis and aggressive intervention to lower the IOP are of
the utmost importance.
• The degree of angle involvement is an important factor in
determining whether a secondary glaucoma will develop.
• Normotensive eyes with angle recession of more than 180° should be
routinely re-examined for an indefinite period to monitor for the
development of late glaucoma.

29. Thank you all….
Special thanks to
•My Guide Professor Dr. Khurshid Alam, &
•My Moderator Dr. S. M. Noman
Next case presentation on 12/10/2017
Topic: Optic neuritis
BY -- Dr. Tahamina Parvin & Dr. Rayhana Begum