What is Traumatic Glaucoma (Eye Injury – Glaucoma)?
Traumatic glaucoma is a form of glaucoma that happens because of eye injury. There are two types of eye injuries: those that involve a closed eye, and those that involve an open eye.
All kinds of eye injuries can result in increased pressure inside the affected eye. If not treated properly, this can cause permanent damage to the optic nerve — the part of the eye that carries visual information to the brain — and potentially lead to permanent vision loss.
In this explanation, ‘traumatic glaucoma’ refers to both glaucoma and ocular hypertension—the condition that doesn’t show changes in the optic disc associated with glaucoma. This term is used for simplicity, and because it can be difficult to perform optic nerve examinations and visual field tests, which are the key methods for diagnosing glaucoma, in patients with eye injuries.
What Causes Traumatic Glaucoma (Eye Injury – Glaucoma)?
Closed-globe trauma refers to non-penetrating injuries to the eye and they can have early or late effects. Early effects of such injuries can include traumatic hyphema, which is bleeding into the front of the eye; traumatic iritis, or inflammation of the colored part of the eye; trabecular meshwork injury, which is damage to a part of the eye that helps with fluid drainage; and suprachoroidal hemorrhage, or bleeding underneath a layer of the eye.
Over time, closed-globe trauma can also have several later effects. These may include unusual responses to steroids; changes to the angle of the eye where fluid typically drains; dislocation or partial dislocation of the lens of the eye which may lead to blockage of the pupil; various types of glaucoma, which is a group of eye conditions that can cause vision loss; or the formation of a carotid-cavernous sinus fistula, which is an abnormal connection between blood vessels near the eye.
On the other hand, open-globe trauma refers to injuries that penetrate the eye. Potential complications from this kind of trauma can include epithelial downgrowth, which is excessive growth of the outer layer of cells in the eye or fibrous downgrowth, which is where fibrous tissue grows excessively.
Risk Factors and Frequency for Traumatic Glaucoma (Eye Injury – Glaucoma)
Eye trauma is a fairly common occurrence, affecting approximately 7 out of every thousand individuals in the United States per year. The most frequent type of eye injury is an orbital fracture. It’s common for patients to experience higher pressure in the eye after undergoing surgery for an open-globe injury. According to research, about 23.3% of these patients experienced high eye pressure, and 6.2% eventually developed glaucoma.
Further studies have found that the onset of glaucoma can occur quite some time after the initial injury. Approximately 3.4% of patients had glaucoma six months after a blunt eye trauma, but the incidence of glaucoma saw a significant jump to 10% when assessed at the ten-year mark. This shows the potential long-term impact of eye trauma and emphasizes the importance of regular check-ups.
- Eye trauma is a common issue, with an incidence rate of around 7 out of every 1000 people in the United States each year.
- The most common form of eye trauma is orbital fractures.
- High eye pressure is common after open-globe injury surgery, with about 23.3% of patients experiencing this.
- Of these patients, 6.2% go on to develop glaucoma.
- Instances of glaucoma can occur some time after the injured, with around 3.4% of patients having it six months after injury and 10% after 10 years.
Signs and Symptoms of Traumatic Glaucoma (Eye Injury – Glaucoma)
This discussion will cover how to manage increased eye pressure following a traumatic event, with the assumption that the immediate injury has already been addressed. We will not be discussing how to handle eye trauma as it happens.
When treating someone for such an issue, it’s crucial to gather a detailed account of the accident that led to the injury. The circumstances of the trauma should be clearly recorded, taking note of when it happened, how it happened, and in what environment it happened. You should also consider whether a foreign object was involved, paying attention to the object’s distance, speed, and trajectory if applicable.
Make sure to document any treatment or operations previously undergone for the trauma. The timing of the rise in eye pressure relative to the injury and treatment should also be identified. Past eye and medical histories, including pre-existing cases of glaucoma, eye surgeries, bleeding disorders, genetic diseases, and the use of certain medications, should also be recorded.
Depending on the patient’s history, there might be a need to consider the likelihood of traumatic optic neuropathy and traumatic brain injury as they could affect how the physical examination and visual field tests are interpreted. You may also need to review past letters from previous doctors, hospital discharge letters, and reports (and the actual imagery) from imaging tests.
During the physical examination, check things such as visual sharpness, eye pressure (ideally using Goldmann applanation tonometry), and pupil responses. Other aspects to assess include optic nerve function signs like red and brightness saturation and color perception issues. This can help identify whether non-glaucoma causes, such as traumatic optic neuropathy, are contributing to any optic nerve dysfunction.
- Visual sharpness
- Eye pressure
- Pupil responses
- Signs of optic nerve function issues
- Color perception issues
To adjust correctly for the eye pressure measurement, the central corneal thickness should be measured using techniques such as ultrasound pachymetry, anterior segment optical coherence tomography, Schleimpflug (pentacam) tomography, or similar.
The remaining portion of the physical examination can be divided into several key aspects:
- Recent injuries might cause changes in the anterior chamber of the eye
- The corneal endothelium may show certain abnormalities
- The iris may display various irregularities
- Gonioscopy may reveal signs of trauma
- The lens might show signs of certain issues
- The back of the eye could show various abnormalities
If glaucoma has already set in, the optic disc, located at the back of the eye, may have a concave appearance.
Testing for Traumatic Glaucoma (Eye Injury – Glaucoma)
An ultrasound B-scan might come in handy when a view of the back of the eye is obscured, such as when there is a thick, long-lasting blood clot in the eye.
In certain situations, specialised tests may be needed. An ultrasound biomicroscopy (UBM) can be beneficial when dealing with traumatic cataracts to spot and evaluate invisible structural defects in the eye. This test is also good for examining the front part of the eye, such as the angle structures and the ciliary body, when conditions like angle recession, iridodialysis, and cyclodialysis cleft are suspected. It is very effective for diagnosing, especially in cases where the view of the front part of the eye is restricted by opacity in the eye’s structure and distortion of anatomy.
Specular microscopy can provide useful information in cases of epithelial downgrowth, a condition involving abnormal tissue growth. This test may help to differentiate between the epithelial membrane and the endothelium, a thin layer of tissue at the back of the cornea, especially in cases of a retrocorneal epithelial membrane. However, this technique requires a relatively clear cornea and won’t be much help if corneal edema or swelling of the cornea is present. Anterior segment OCT might be helpful in identifying the origin of the unnatural tissue growth. But, to confirm the diagnosis, an aqueous tap and cytology (a test to study cells and their function) or a tissue biopsy of the membrane needed to be performed.
Treatment Options for Traumatic Glaucoma (Eye Injury – Glaucoma)
When a person experiences an injury to the eye without a cut (known as closed-globe trauma), the medical interventions required can differ depending on how soon after the injury medical help is sought and the specifics of the damage done.
For instance, when a patient suffers from a bleed in the eye (hyphema) caused by trauma, treatment typically begins with prescribed corticosteroids and eye drops to relax the iris. The patient will also be advised to keep to bed rest in a specific posture to help clear their vision and should wear a rigid plastic eye shield to avoid further injury. It may be necessary to stop taking certain medicines that could increase bleeding.
Some patients may be advised to stay under close medical supervision, particularly those who are likely to not commit to treatment instructions, children, those who experience a re-bleed, and patients with certain hereditary blood disorders (sickle cell trait or disease). For those whose eye pressure increases in response to hyphema, a step-by-step process of medication application is initiated.
In certain cases, surgery may be considered if medical treatment is not effective. This could include patients who have high eye pressure that isn’t responding to medication. A few guidelines suggest surgery in cases of incredibly high eye pressure, with more conservative approaches for those with sickle cell trait or disease.
Trauma can also lead to inflammation of the iris (iritis), where the main treatment involves corticosteroids and cycloplegia. Some other forms of trauma may include trabecular meshwork injury and suprachoroidal hemorrhage, for which doctors generally recommend medication and rest.
Late-onset issues related to eye trauma reject a whole other type of consideration, which becomes possibly due to steroid response or injury to the eye angle (recession). For instance, a patient who responds to steroids and has certain risk factors should be closely monitored when using corticosteroids. Generally, injury to the eye angle requires regular check-ups to detect potential glaucoma.
Lens subluxation and dislocation may be detected, and patients may develop a type of glaucoma caused by the maturity of the lens (phacomorphic glaucoma), where surgical removal of the lens is the definitive treatment.
There are also cases where a type of glaucoma can develop due to an immune response to the eye’s own proteins (phacoantigenic glaucoma), in which lens extraction is usually required. Several other forms of late-onset irregularities, due to glaucoma related to the debris of red blood cells in the vitreous humor of the eye (ghost cell glaucoma), may occur due to a buildup of hemoglobin products (hemolytic glaucoma), iron storage diseases (hemosiderotic glaucoma), and fistula (abnormal connection) between the carotid artery and the cavernous sinus at the base of the brain (carotid-cavernous sinus fistula).
Another type, open-globe trauma, may result in the unusual cell growth inside the eye, which can be of epithelial type or fibrous. For both types, the conventional course of pressure-lowering surgery tends to fail, and the drainage tube surgery is preferred. In extreme cases, destroying part of the ciliary body may be a last resort.
What else can Traumatic Glaucoma (Eye Injury – Glaucoma) be?
“Traumatic glaucoma” refers to a rise in eye pressure, known as IOP, caused by injury. This term encompasses a lot of different reasons why this might happen. So, when a doctor is trying to diagnose the cause of the increased eye pressure, they need to bear in mind all these various causes under the label of “traumatic glaucoma”. This helps them to decide on the best treatment plan.
What to expect with Traumatic Glaucoma (Eye Injury – Glaucoma)
The outlook for traumatic glaucoma can differ greatly, depending on what’s causing it. There are several conditions – including traumatic hyphema, iritis, steroid-response, lens-related glaucoma, ghost cell glaucoma, hemolytic glaucoma, and hemosiderotic glaucoma – that typically have a better outcome, as long as the source causing the increase in eye pressure is dealt with appropriately.
Possible Complications When Diagnosed with Traumatic Glaucoma (Eye Injury – Glaucoma)
In some rare cases, despite multiple medical and surgical interventions, the intraocular pressure (IOP) in traumatic glaucoma can remain high. If not controlled, this can lead to severe and irreversible changes in the optic disc resulting in permanent blindness.
Preventing Traumatic Glaucoma (Eye Injury – Glaucoma)
Patients should receive understandable information about what’s causing their health problems, the different ways it can be treated, and the plan for moving forward. All of this should be explained in simple, everyday language. If the plan includes surgery, it’s important to clearly outline both the potential risks and benefits. This way, the patient can make a well-informed decision about their treatment.