FP1630 : Characteristics for Early Predictors of Traumatic Glaucoma After Closed Globe Injury

Dr. Sujana Inampudi, I18220, Dr.Sumita Mohapatra, Dr. Sikha Misra, Dr. Nilamadhab Pradhan

PRESENTING AUTHOR: SUJANA INAMPUDI

CO-AUTHORS: SUMITA MOHAPATRA, SIKHA MISRA, NILAMADHAB PRADHAN

INTRODUCTION:

Trauma is a common cause of ocular morbidity .Ocular trauma is usually classified as post blunt or penetrating injuries with Indian data documenting blunt injuries to be responsible for almost 55% cases. Glaucoma onset depends on type of trauma which is concussion (closed globe) or penetrating (Open globe).

Traumatic glaucoma is a secondary glaucoma, indicates the severity of the eye injury. It appears in 5–10% of the injured eyes. It may appear immediately after injury in a form of acute glaucoma or later as chronic angular glaucoma.

In the closed globe injury, as the liquid content of the eye is non compressed, the hydrodynamic blow is being transmitted to the internal structures causing iridodialysis, angle recess, bleeding into the anterior chamber and vitreous, zonulorexis with subluxation and luxation of the lens, and damage to the choroid and retina. Due to a prolapse of  vitreous, lens and blood, there may be obstruction of the angle of chamber and pupillary block may develop, with a rapid increase of intraocular pressure (IOP).

Hence, Glaucoma after closed globe injury is a major concern because many cases may go unnoticed and, without close follow-up, are diagnosed many years later. Therefore timely and appropriate management of these injuries may restore vision to a greater extent than in those with underlying primary pathology .

AIM OF THE STUDY:

Present study is aimed at studying the early predictors of traumatic glaucoma after closed globe injury at a tertiary referral eye centre RIO in Eastern India

MATERIALS AND METHODS:

This is a Prospective observational study of 192 pts >12yrs with closed globe injury who presented to our hospital, RIO between August 2014 to January 2016

Patients initially seeking treatment in the ophthalmic casualty department after a closed globe injury during a 1&1/2-yr period were included for evaluation.

Exclusion criteria

  1. An open globe injury
  2. Primary glaucoma or other pre existing cause of secondary glaucoma
  3. A history of ocular surgery or laser therapy
  4. Cases with consultation done before presentation to our Institute
  5. With poor visual acuity of the injured eye prior to injury
  6. With follow up of less than four months

After taking informed and written consent, Relevant history included patient details and Details of the ocular injury—mode of injury, zone of injury ,time from trauma to initial visit, and route, dose and duration of therapy recorded.

Prior ocular problems and a family history of glaucoma were also noted.

A thorough ocular examination of both eyes was performed, including best corrected visual acuity, slitlamp biomicroscopic examination, fundus examination with a +90D lens and indirect ophthalmoscopy without indentation.

Intraocular pressure (IOP) measurements on at least 3 occasions were recorded by means of applanation tonometry.

Four weeks after the trauma, gonioscopy and UBM were performed.

On gonioscopy, the circumferential extent of angle recession and cyclodialysis were noted and pigmentation was graded as 0 (no pigmentation), 1 (faint), 2 (average), 3 (heavy), or 4 (very heavy).6

Ultrasonographic biomicroscopy was performed to find out angle recession, cyclodialysis, iridodialysis, and lenticular subluxation or dislocation.

All patients were followed up every month for 6months and as appropriate thereafter. At each visit, best corrected visual acuity, applanation tonometry, and thorough anterior and posterior segment evaluations were performed.

In the presence of a hyphema, patients underwent evaluation more frequently to monitor

the IOP and corneal status.

All patients with post traumatic uveitis were treated with corticosteroids for a maximum of 2 weeks. For an elevated IOP, they were treated with betablockers, brimonidine, or dorzolamide hydrochloride topically and systemic antiglaucoma medications where necessary.

Eyes with an elevated IOP (> or =21mmHg) and requiring glaucoma therapy for at least 3 months after closed globe injury were diagnosed as having a traumatic glaucoma.

In the absence of such a chronically elevated IOP or evidence of glaucomatous optic neuropathy, eyes were diagnosed as having only a closed globe injury without glaucoma

RESULTS :

We reviewed 192 eyes of 192 consecutive patients older than 12 years who had had a recent closed globe injury. 127 patients fulfilled inclusion criteria for the study after exclusion of 13 patients with primary glaucoma, 13 patients with pseudophakia, 7 patients who had undergone a recent vitreoretinal surgery, and 32 patients with lost followup.

Twenty three (23) of the 127 patients (18.1%) had a persistent elevation of IOP (>21 mm Hg) for at least 3 months, i.e, traumatic glaucoma. The remaining 104 patients (81.88%) had an IOP consistently less than 21 mm Hg, with no evidence of glaucomatous optic neuropathy; these patients constituted the closed globe injury group. Demographic data are presented in

Table 1

Table 1
Demographic data of Study subjects
Characteristic Closed globe injury

with out

glaucoma

N =104 (%)

 

Traumatic

Glaucoma

N = 23 (%)

 

                        Gender
Male 75 (72) 13 (56.5)
Female 29 (27.9) 10 (43.5)
Wound Location
Zone 1 53 (50) 4 (17.3)
Zone 2 39 (37.5) 18 (78.2)
Zone 3 12 (11.5) 1 (4.3)

We classified the closed globe injury group without glaucoma by the zone of injury, 53 (50%) had a zone 1 injury; 39 (37.5%) had a zone 2 injury; and 12 (11.5%) had a zone 3 injury.

The respective numbers in the traumatic glaucoma group were 4 (17.3%), 18 (78.2%), and 1(4.3%) .

Clinical findings are listed in Table 2.

Hyphema, baseline IOP, trabecular pigmentation, and lens displacement were statistically more frequent in the traumatic glaucoma group. Four patients with traumatic glaucoma had a recurrence of bleeding within 5 days of the trauma, compared with none of the patients with a closed globe injury.

A mean baseline IOP of 17.3 (5.0) mm Hg was recorded in the closed globe injury group and 35.2 (12.8) mm Hg in the traumatic glaucoma group (P=0.03).

Gonioscopic examination of the closed globe injury group revealed that 84 eyes had a normal angle structure. In 8 eyes, a iridodialysis was noted. Of the remaining 12 eyes, 6 had angle recession of less than 180°, 4 of 180° to 270° and 2 of more than 270°.

Table 2

Clinical findings in eyes with closed globe injuries with and with out glaucoma

Closed globe injury

with out

glaucoma

N =104 (%)

Traumatic

Glaucoma

N = 23 (%)

 

P VALUE

VA < 6/60 24 (23) 14 (60.8) 0.03
MEAN (SD) base IOP

MM hg

17.3 (5) 35.2 (12.8) 0.03
ANTERIOR SEGMENT
Hyphaema 44 (42.3) 12 (52.9) 0.03
Sphincteric tears 36 (34.6) 2 (8.6) 0.44
Iridodialysis 8 (7.7) 1 (4.3) 0.43
Trabecular pigmentation

G > 3

14 (13.4) 6 (26.4)  

0.15

Angle  recession 12 (11.5) 2 (8.8) 0.49
LENTICULAR  FEATURES
Cataract 14 (13.4) 4 (16) 0.26
Subluxation of lens 16 (15.3) 8 (38) 0.55
POSTERIOR SEGMENT
Vitreous Hemorrhage 10 (9.6) 4 (16) 0.26
Choroidal rupture 8 (7.7) 3 (13) 0.67
Macular oedema 22 (21.1) 6 (26.4) 0.33
Retinal dialysis 12 (11.5) 3 (13) 0.67

In the traumatic glaucoma group, gonioscopic findings revealed that 20 eyes had normal angles, whereas 2 eyes (8.8%) had angle recession less than 180°.

The trabecular pigmentation seen in eyes with traumatic glaucoma (median grade, 3; range, 2-4) was significantly more compared with that in eyes without glaucoma (median grade, 2; range, 1-4).

Trabecular pigmentation of at least grade 3 was seen in 14 eyes (13.4%) in the closed globe injury group and in 6 eyes (26.4%) in the traumatic glaucoma group, correlatin with the presence of traumatic glaucoma ( P =0.15). The extent of pigmentation was not related to the extent of angle injury alone, but was also probably a result of other ciliary body and iris damage.

Table 3

Relative Risk of Developing a Chronic Glaucoma

Based on Clinical Features of All Eyes

After Closed Globe Injury

Features Seen  < 4 wk After Injury Relative risk

(95% CI)

VA < 6/60 2.5  (1.5 – 4)
BASELINE IOP 1.3  (1.1 – 1.5)
Hyphaema 6.9  (2.3 – 20.6)
Cataract 3.5  (1.6 – 7.4)
Lens subluxation 1.7  (1.1 – 2.7)
Angle recession > 180 3.3  (2 – 5.25)
Angle recession 360 7.5  (1.9 – 28.8)
Trabecular pigmentation G > 3 20.8  (4.5 – 95.8)
Posterior seg involvement 1.4  (0.8 – 2.3)

The relative risk of developing chronic glaucoma in an eye with closed globe injury, based on clinical features seen at presentation, was greatest if there was heavy pigmentation of the trabecular meshwork, an elevated baseline IOP, hyphema, angle recession. (Table 3).

In the closed globe injury group, the mean IOP at the 3-month follow-up was 16.2 (3.2) mm Hg and at 6 months, 14.7 (3.8) mm Hg. In the traumatic glaucoma group, the mean IOP was 20.4 (4.1) mmHg and 18.7 (4.8) mm Hg at 3 and 6 months, respectively.

DISCUSSION:

Glaucoma after blunt trauma appears to have 2 peaks of incidence, at less than 1 year and about 10 years after trauma, by which time acute symptoms and signs of trauma have subsided and the patient is unaware of a chronically elevated IOP. It is important to be able to identify eyes at risk for such a chronic traumatic glaucoma and to review them carefully, so that appropriate therapy may be initiated as early as possible.

In our study, the anterior chamber angle was carefully studied by means of gonioscopy . The presence of heavy trabecular pigmentation (grade > 3) was a significant predictor of chronic glaucoma, with a relative risk of 20.8

Extensive release of pigment into the eye during trauma could clog the trabecular meshwork, and trabecular endothelial cells that phagocytize the pigment particles could also block the meshwork, directly and through changes induced at the meshwork.

The baseline IOP of eyes developing chronic glaucoma was higher than that of eyes that did not, with a range of 22 to 60 mmHg compared with a range of 10 to 28 mm Hg. This has not been previously reported because most studies were retrospective. The elevated IOP at baseline probably reflects decreased aqueous outflow due to extensive primary damage, inflammation, and pigment release at the trabecular meshwork.

We noted that hyphema also a significant predictor for traumatic glaucoma with relative risk 6.9

we found hyphema in 52.9% eyes in traumatic glaucoma group

The features that were significantly associated with traumatic glaucoma—hyphema, an angle recession of more than 180°, displacement of the lens, and trabecular pigmentation—could all be attributed to ciliary body damage. These ciliary body injuries would lead to an inflammatory

response not only at the site of injury, but also throughout the ciliary body and in the contiguous iris and trabecular meshwork. Resolution of uveal inflammation and injury is generally by a fibroblastic response, as seen in the iris or the choroid. Such a reparative process in the ciliary body would necessarily involve the adjoining trabecular meshwork, decreasing aqueous outflow and raising IOP.

In conclusion, increased pigmentation of the angle on gonioscopic findings, a higher baseline IOP, along with the features of hyphema, angle recession, lens subluxation are the significant predictors which have to be looked for in development of chronic glaucoma

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  11. Salmon JF, Mermoud A, Ivey A, Swanevelder SA, Hoffman M. The detection of post-traumatic angle recession by gonioscopy in a population based glaucoma survey. Ophthalmology. 1994;101(11):1844-1850.almological Numismatics
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