Glaucoma after Trauma

Cynthia V. Verzosa, MD, DBPO, MSc

• photos
 Objectives
• Know the pathophysiology of post-traumatic
glaucoma
• Recognize traumatic eye conditions that may
lead to glaucoma
• Know the salient points in managing post-
traumatic glaucoma
 Ocular trauma
• Incidence
– ~ 2M individuals experienced eye injury (2001)
– 7 per 1000 population
– Profile : White, male, 20s
– 10-20% results in vision loss

McGwin G, Xie A, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol.
2005; 123:970-076.
 Glaucoma after ocular contusion
• Hyphema
• Lens injury
• VA worse than 20/200
• Angle recession
• Iris injury
• Advancing age

Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular contusion: a
cohort study of the United States Eye Injury Registry. Journal of Glaucoma. 2005;
14(6): 470-3.
How do you
develop
glaucoma after
trauma?
Anatomy of a blunt trauma
 7 rings
of
trauma

Adapted from Campbell DG. Traumatic glaucoma. In Singleton BJ, Hersh PS, Kenyon KR [eds]: Eye Trauma, St. Louis, Mosby, 1991 ).
 Glaucoma post trauma

• Decreased aqueous outflow

– Blockage of trabecular meshwork
– Swelling of the trabecular meshwork
– Disruption of the trabecular meshwork
 Glaucoma post trauma
• Traumatic hyphema
• Angle recession
• Lens injury
• Vitreous hemorrhage
 Glaucoma post trauma
• Traumatic hyphema
• Angle recession
• Lens injury
• Vitreous hemorrhage
Traumatic hyphema
 Traumatic hyphema
• 30% of patients with hyphema - IOP elevation
• IOP elevations tend to be self-limited
• Beyond 5-7 days of IOP > 35 mmHg –
increased risk of glaucomatous optic
neuropathy

Read J, Goldberg MF. Comparison of medical of traumatic hyphema. Trans Am Acad

Oophthalmol Otolaryngol 1974; 78:799.
 Traumatic hyphema

• Risk of IOP rise increases with larger hyphema

– Grades 1-2 13.5%
– Grade 3 27%
– Grade 4 52%

Coles WH. Traumatic hyphema: an analysis of 235 cases. South Med J. 1968;61:813-816
 Traumatic hyphema
• SLE
– Blood in the AC
– Grade the hyphema (Gr 0- IV)
• Total hyphema vs 8-ball hyphema*

– Check for damage to the iris, pupil, lens, angles

*Bazzaz S, Katz JL, Myers JS. Post traumatic glaucoma. In:Shaarawy T, Sherwood MB, Hitchings
RA, Crowston JG, eds. Glaucoma: Medical Diagnosis and Therapy. Elservier: 2009; 431-439.
 Traumatic hyphema
• Rebleeding
– Highest risk 2-5 days post-trauma
– Incidence variable
– >50% chance of having IOP elevations
– Risk factors
• African-American
• Patient who present more than 24 hours post injury
• Patients taking anticoagulants

Volpe NJ, Larrison WI, Hersh PS, et al. Secondary hemorrhage in traumatic hyphema. Am J
Ophthalmol 1991; 106:383-390.
Coles WH. Traumatic hyphema: an analysis of 235 cases. South Med J. 1968;61:813-816
 Traumatic hyphema
• Treatment
– Eye shield
– Head elevation (45°)
– Limitation of activities
– Hospitalization
• Noncompliant patient
• Bleeding disorders
• Severe ocular injuries
 Traumatic hyphema
• Treatment
– Topical steroids
– Topical cycloplegics
– Consider giving anti-fibrinolytics (aminocaproic
acid, tranexamic acid)
– Topical aqueous suppressants
• β blockers
• α agonists
• CAIs
 Traumatic hyphema
• Surgery
– 5% of patients will need surgery
– Indications
• Uncontrolled IOP last more than 5 days
• Corneal blood staining
• Large or total hyphema
• Active bleeding in AC

Andreoli CM, et al. Traumatic hyphema; epidemiology, anatomy, pathophysiology.

UptoDate, 2011.
 Glaucoma post trauma
• Traumatic hyphema
• Angle recession
• Lens injury
• Vitreous hemorrhage
Angle recession
 Angle recession

• Incidence following blunt ocular trauma with

hyphema: 50-100%

Volpe NJ, Larrison WI, Hersh PS, et al. Secondary hemorrhage in traumatic hyphema. Am J
Ophthalmol 1991; 106:383-390.
 Angle recession glaucoma

• Incidence: 6% in patients with recession*

• Onset: months to years post trauma**

*Kaufman J, Tolpin D. Glaucoma after traumatic angle recession. Am J Ophthalmol.

1974;78:648-654
**Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular contusion: a cohort
study of the United States Eye Injury Registry. Journal of Glaucoma. 2005; 14(6): 470-3.
 Angle recession glaucoma

• Incidence of glaucoma with recession

– Correlated with extent of angle involvement
– Risk highest if 240° or more of angle is involved

Canavan YM, Archer DB. Anterior segment consequences of blunt ocular injury. Br J
Ophthalmol 1982; 66:549
Blanton FM. Anterior chamber angle recession and secondary glaucoma. A study of the after
effects of traumatic hyphema. Arch Ophthalmol 1964;72:39
 Angle recession glaucoma
• Glaucoma
– Early onset – inflammation, obstruction
– Late onset – scarring and fibrosis of the TM and
Schlemm’s canal, formation of membrane over TM
 Angle recession glaucoma
• SLE
– Deep AC
– Widened cbb
• Examine the
unaffected eye first
 Angle recession glaucoma
• Treatment – like POAG
– Topical and oral aqueous suppressants
– NO pilocarpine
– ALT is NOT effective
– Filtration surgery, GDD insertion
 Glaucoma post trauma
• Traumatic hyphema
• Angle recession
• Lens injury
• Vitreous hemorrhage
 Lens injury
• Types
– Lens dislocation
– Lens swelling (phacomorphic glaucoma)
– Phacolytic glaucoma
– Lens particle glaucoma
 Lens injury
• Elevated IOP
– Pupillary block
– Blockage of TM
– Damage of TM
 Lens injury
• SLE
– AC reaction
– Subluxed/dislocated crystalline lens
– Cataract
• Treatment
– Lensectomy ± vitrectomy
 Glaucoma post trauma
• Traumatic hyphema
• Angle recession
• Lens injury
• Vitreous hemorrhage
 Vitreous hemorrhage
• Glaucoma due to vitreous hemorrhage
– Blockage of TM by cells and cellular debris
– Hemolytic glaucoma
– Ghost cell glaucoma

Spraul CW, Grossnikalus HE. Vitreous hemorrhage. Surv Ophthalmol. 42:3-39, 1997.
 Vitreous hemorrhage
• Hemolytic glaucoma
– SLE
• Free hemoglobin, hemoglobin laden macrophages and
RBC debris block TM
• Reddish brown discoloration of the TM
 Vitreous hemorrhage
• Ghost cell glaucoma
– SLE
• Crenated RBCs that develop 1-3 months after
hemorrhage
• Khaki colored cells
• Tan hypopyon
 Vitreous hemorrhage
• Treatment of glaucoma
– Aqueous suppressants
– AC irrigation
– Vitrectomy
 Case
• 11 year old male
• HPI
– 10 days ago – hit by ball on right eye
– Consult at ER: VA OD 20/25, Grade 1 hyphema, +1
c/f, IOPs mid teens
– Meds: Prednisolone, Tobramycin, Atropine,
Tranexamic acid
 Case
• Followup: Gradual rise of IOP, receding
hyphema
• Gonioscopy: recession of angles from 3-9
o’clock
• IOP rise?
– Blocked TM
– Steroid response
– Angle recession
Summary
• Blunt ocular trauma results the sudden
compressive deformation of the globe
• Injury to 7 circles of tissue at the equatorial
zone, specifically the anterior ciliary body and
the trabecular meshwork
• Glaucoma occurs due to decreased a queous
outflow after trabecular meshwork damage,
inflammation, or blockage
Summary
• Conditions that lead to glaucoma post trauma
– Traumatic hyphema
– Angle recession
– Lens injury
– Vitreous hemorrhage
• Treatment: decrease aqueous production,
reduce inflammation, surgery
 References
• McGwin G, Xie A, Owsley C. Rate of eye injury in the United States. Arch Ophthalmol.
2005; 123:970-076
• Bai HQ, Yao L, Wang DB, Jin R, Wang YX. Causes and treatments of traumatic
secondary glaucoma. European Journal of Ophthalmology, 2009; 19(2): 201-206.
• Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular contusion: a
cohort study of the United States Eye Injury Registry. Journal of Glaucoma. 2005;
14(6): 470-3.
• Campbell DG. Traumatic glaucoma. In Singleton BJ, Hersh PS, Kenyon KR [eds]: Eye
Trauma, St. Louis, Mosby, 1991).
• Read J, Goldberg MF. Comparison of medical of traumatic hyphema. Trans Am Acad
Oophthalmol Otolaryngol 1974; 78:799.
• Coles WH. Traumatic hyphema: an analysis of 235 cases. South Med J. 1968;61:813-
816
• Bazzaz S, Katz JL, Myers JS. Post traumatic glaucoma. In:Shaarawy T, Sherwood MB,
Hitchings RA, Crowston JG, eds. Glaucoma: Medical Diagnosis and Therapy. Elservier:
2009; 431-439.
 References
• Andreoli CM, et al. Traumatic hyphema; epidemiology, anatomy,
pathophysiology. UptoDate, 2011.
• Volpe NJ, Larrison WI, Hersh PS, et al. Secondary hemorrhage in traumatic
hyphema. Am J Ophthalmol 1991; 106:383-390.
• Canavan YM, Archer DB. Anterior segment consequences of blunt ocular
injury. Br J Ophthalmol 1982; 66:549
• Blanton FM. Anterior chamber angle recession and secondary glaucoma. A
study of the after effects of traumatic hyphema. Arch Ophthalmol 1964;72:39
• Kaufman J, Tolpin D. Glaucoma after traumatic angle recession. Am J
Ophthalmol. 1974;78:648-654
• Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular
contusion: a cohort study of the United States Eye Injury Registry. Journal of
Glaucoma. 2005; 14(6): 470-3.
Thank you for your attention