What is the management and treatment for angle recession?

Management and Treatment of Angle Recession

The management of angle recession should focus on controlling intraocular pressure (IOP) through medical therapy first, followed by surgical intervention if necessary, with the goal of preventing glaucomatous optic nerve damage and preserving vision. 1

Initial Assessment and Diagnosis

• Gonioscopic examination is essential to diagnose angle recession, which appears as a deepened angle recess or approach in the anterior chamber 1
• Evaluate the extent of peripheral anterior synechiae (PAS) formation using dark-room gonioscopy with compression/indentation 1
• Assess for trabecular damage which may have occurred during iridocorneal apposition 1
• Rule out other causes of secondary angle closure that may coexist with angle recession 1

Medical Management

• First-line treatment includes topical ocular hypotensive agents similar to those used for primary open-angle glaucoma 1
• Agents that suppress aqueous humor formation are typically used, including:
  • Topical beta-adrenergic antagonists 1
  • Topical alpha2-adrenergic agonists 1
  • Topical or oral carbonic anhydrase inhibitors (acetazolamide is FDA-approved for secondary glaucoma) 2
• Miotics (parasympathomimetics) may be used but are controversial in angle recession glaucoma 3

Laser Therapy Options

• Laser trabeculoplasty has shown variable results in angle recession glaucoma:
  • Nd:YAG laser trabeculopuncture (YLT) has demonstrated better success rates than argon laser trabeculoplasty (ALT) in small studies 4
  • Selective laser trabeculoplasty (SLT) may be beneficial in some cases, though evidence is limited 5
• Laser peripheral iridotomy (LPI) is indicated if there is a component of pupillary block contributing to the angle closure 1

Surgical Management

• Surgery is indicated when medical therapy fails to control IOP adequately 6
• Surgical options include:
  • Trabeculectomy with antimetabolite therapy has shown superior outcomes compared to trabeculectomy alone or Molteno implantation 6
  • Glaucoma drainage devices may be considered in cases resistant to other treatments 6
  • Goniosynechialysis may improve aqueous outflow if performed within 6-12 months of injury 1

Follow-up and Monitoring

• Regular follow-up evaluations should include:
  • IOP measurement 1
  • Gonioscopy to assess for progression of PAS 1
  • Optic nerve examination and visual field testing to monitor for glaucomatous damage 1
• The fellow eye should also be carefully evaluated, as bilateral angle recession can occur, particularly in cases of airbag injuries or other bilateral trauma 7

Special Considerations

• Angle recession glaucoma may develop years after the initial trauma, necessitating long-term monitoring 3
• Patients with more extensive angle recession (>180°) are at higher risk for developing glaucoma 3
• Late bleb infection is a significant risk in patients who undergo trabeculectomy with antimetabolite therapy 6
• Bilateral angle recession should prompt investigation for causes such as airbag deployment or history of repeated trauma 7

Treatment Algorithm

1. Initial management: Medical therapy with IOP-lowering medications
2. If IOP remains uncontrolled: Consider laser therapy (YLT or SLT)
3. If laser therapy fails: Proceed to surgical intervention, preferably trabeculectomy with antimetabolite
4. For refractory cases: Consider glaucoma drainage implants