QUIZ WISE – 78
Test your Knowledge and have fun.
Quizwise related to the ImageWise case above.
Right eye gonioscopy image showed normal angles. All angle structures, including the ciliary body band, are visible (red arrow).
Left eye -gonioscopic image showed 360-degree angle recession (red arrow). Note the broad ciliary body band.
Anterior segment imaging of the RE showed an open angle.
Anterior segment imaging of the LE showed a recessed angle.
Q 1. What was the presenting complaint in this case of angle recession glaucoma?
A) Blurred vision
B) Eye pain
C) Routine eye exam
D) Redness
Ans C. The patient presented for a routine eye exam and was incidentally found to have elevated IOP and gonioscopic findings concerning angle recession glaucoma. He did not have any specific vision or eye symptoms.
Q 2. What gonioscopic finding confirms the diagnosis of angle recession glaucoma in this case?
A) Pigmented trabecular meshwork
B) Peripheral anterior synechiae
C) 360-degree angle recession
D) Plateau iris configuration
Ans. C. On gonioscopy, the patient was found to have 360-degree angle recession in the left eye, which points to prior blunt ocular trauma causing damage and malformation of the angle structures. This confirms the diagnosis of angle recession glaucoma.
Q 3. How did the trauma sustained in childhood affect the refractive error in this patient?
A) Caused myopia
B) Caused hyperopia
C) Caused irregular astigmatism
D) No effect
Ans. B. The trauma caused changes, including zonular weakening and angle recession, that led to an increase in axial length but more so in lens thickness, resulting in hyperopia in the left eye.
Q 4. What was the initial management recommended for this patient?
A) Trabeculectomy
B) Laser peripheral iridotomy
C) Observation
D) Topical medications
Ans C. Since the patient did not yet have glaucomatous damage, initial management was observation with close follow-up. Treatment would be initiated only if elevated IOP or evidence of optic nerve damage developed.
Quizwise on angle recession
Q.1 What is the angle recession?
A) Tear between the longitudinal and circular muscles of the ciliary body
B) Separation of the ciliary body from the scleral spur
C) separation of the iris root from its attachment to the anterior ciliary body
D) Increase pigmentation of the trabecular meshwork
Ans A. Blunt trauma exerts traction on the iris root leading to a tear between the longitudinal and circular muscles of the ciliary body. With enough force, the ciliary arteries can be broken, leading to hyphema. A cyclodialysis cleft is formed when the longitudinal fibers of the ciliary muscle separate from the scleral spur, forming a direct connection between the anterior chamber and the suprachoroidal space. Iridodialysis is the separation of the iris root from its attachment to the anterior ciliary body.
De Leon-Ortega JE, Girkin CA. Ocular trauma-related glaucoma. Ophthalmol Clin North Am. 2002 Jun;15(2):215-23. doi: 10.1016/s0896-1549(02)00011-1. PMID: 12229238.
Q.2 Glaucoma in angle recession is due to?
A) Iridodialysis
B) Associated lens subluxation
C) Damage to Trabecular meshwork
D) Tears in the ciliary body
Ans C. Angle recession glaucoma (ARG) is a secondary open-angle glaucoma that is associated with ocular trauma. The initial insult could potentially harm the trabecular meshwork (TM) and Schlemm’s canal, resulting in an immediate increase in intraocular pressure (IOP). Nevertheless, prolonged scarring and fibrosis of the TM and Schlemm’s canal might lead to elevated pressure in the future. The angle’s recession itself is not necessarily responsible for the damage to outflow structures, but it is a precursor to microscopic trabecular damage.
Pujari A, Selvan H, Behera AK, Gagrani M, Kapoor S, Dada T. The Probable Mechanism of Traumatic Angle Recession and Cyclodialysis. J Glaucoma. 2020 Jan;29(1):67-70. doi: 10.1097/IJG.0000000000001358. PMID: 31460884
Q.3 What is the incidence of glaucoma following angle recession?
A) 1 -5 %
B) 5 -20 %
C) 15- 25%
D) 25 to 50 %
Ans B. On average, 5 to 20 percent of patients with angle recession will eventually develop glaucoma. Individuals with 180° or more of angle recession have a higher likelihood of developing glaucoma. Among them, up to 50 percent may eventually develop glaucoma in their fellow eye.
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 Nov;101(11):1844-50. doi: 10.1016/s0161-6420(94)31091-8. PMID: 7800367.
Q.4 The procedure of anterior chamber wash in traumatic hyphema is performed in which setting?
A) IOP rise of more than 50 mm Hg for 5 days
B) IOP of more than 35 mm Hg for greater than 7 days
C) Persistent hyphema for more than 10 days on maximal medical therapy
D) All of the above
Ans D. During the subacute phase, if there is a continuous increase in intraocular pressure (IOP) exceeding 50 mm Hg for a duration of 5 days, an IOP surpassing 35 mm Hg for more than 7 days, or a persistent hyphema lasting beyond 10 days despite maximum medical treatment, it may be necessary to perform an anterior chamber (AC) washout. Other indications for surgery include corneal blood staining and visual obstruction in children at risk for amblyopia. This procedure aims to reduce the risk of optic nerve damage, the formation of peripheral anterior synechiae (PAS), and the development of corneal blood staining. For individuals with sickle cell disease, an anterior chamber (AC) washout should be considered if the IOP remains above 30 mm Hg for more than 24 hours.
Walton W, Von Hagen S, Grigorian R, Zarbin M. Management of traumatic hyphema. Surv Ophthalmol 2002;47:297-334.
Q 5. What is a common clinical feature of angle recession glaucoma?
A) Ciliary body detachment
B) Central corneal opacity
C) Traumatic mydriasis
D) Retinal hemorrhage
Ans C. Angle recession glaucoma results from traumatic compression and subsequent malformation of the anterior chamber angle structures. Traumatic mydriasis is a classic clinical sign.
(Yanoff & Duker, Ophthalmology, 4th ed., 2014).
Q 6. Which imaging modality is most useful for diagnosing angle recession glaucoma?
A) B-scan ultrasonography
B) Gonioscopy
C) Fundus photography
D) Optical coherence tomography
Ans B. Gonioscopy allows direct visualization of angle abnormalities and is the most useful imaging technique for diagnosing angle recession glaucoma. Signs such as angle recession, cyclodialysis clefts, and iris sphincter tears can be seen.
(Shields Textbook of Glaucoma, 6th ed., 2011).
Q 7. What is the initial management for angle recession glaucoma?
A) Phacoemulsification
B) Laser peripheral iridotomy
C) Trabeculectomy
D) Topical anti-glaucoma medications
Ans D. The initial management for angle recession glaucoma is typically topical anti-glaucoma medications. Surgery is reserved for cases refractory to medical therapy.
(Yanoff & Duker, Ophthalmology, 4th ed., 2014).
Q 8. Which laser procedure may be used in angle recession glaucoma treatment?
A) Selective laser trabeculoplasty (SLT)
B) Laser peripheral iridoplasty
C) Cyclophotocoagulation
D) Peripheral iridotomy
Ans A. Selective laser trabeculoplasty (SLT) works by targeting the trabecular meshwork to increase aqueous outflow and lower intraocular pressure. It is sometimes used as a laser procedure for angle recession glaucoma. It causes less damage than argon laser trabeculoplasty. Peripheral iridotomy is not useful in angle recession disease.
(Glaucoma, Basic and Clinical Science Course, American Academy of Ophthalmology, 2019-2020).
Q