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Traumatic Glaucoma

Traumatic Glaucoma
Chat from September 21, 2011
Guest Speaker – Dr. Anand Mantravadi
Steven Beck, Editor
Lorraine Miller, Editor, Chat Topic Researcher

On Wednesday, September 21, 2011, Dr. Anand Mantravadi, a glaucoma specialist at Wills, and the glaucoma chat group discussed “Traumatic Glaucoma”.

Moderator: Tonight’s topic is “Traumatic Glaucoma”. What is traumatic glaucoma?

Dr. Anand Mantravadi: Traumatic glaucoma is glaucomatous damage that affects the optic nerve that results from a traumatic injury. Glaucomatous optic atrophy is a characteristic type of optic nerve damage for which a major risk factor is elevated intraocular pressure. Trauma of many kinds can lead to damage to structures within the eye that can lead to elevated pressures by a wide variety of mechanisms.

P: What types of injuries cause traumatic glaucoma?

Dr. Anand Mantravadi: Injury mechanisms are vast and varied. Examples include blunt force injuries, sharp injuries, penetrating and non-penetrating injuries, chemical injuries, and thermal injuries. The list is fairly large, but anything that cause injury to the body that you can think of can certainly cause injury to the eye and the delicate structures within.

P: Are secondary glaucoma and traumatic glaucoma the same?

Dr. Anand Mantravadi: Secondary glaucoma is a broad term to imply that glaucoma was “caused by something that is identifiable.” This differs from primary glaucomas where the process is without another identifiable cause.

P: Do these injuries always take the person to the ER or can this injury heal on its own?

Dr. Anand Mantravadi: It depends on the extent and the severity of the injury.

P: How do these injuries change the eye?

Dr. Anand Mantravadi: This is a tough question to answer broadly, as it will largely depend on the severity of the injury. If you have a sharp injury that penetrates the eye, that is a surgical emergency. If you have a blunt injury, this can range from mild to severe, and severe injuries can damage several structures in the eye.

P: Can you tell by the injury if glaucoma will ensue later in life?

Dr. Anand Mantravadi: Good question. You can certainly ascertain “likelihood.”
If the area of the eye responsible for draining aqueous humor (fluid within the eye), is damaged there is a higher likelihood that the person can develop problems with eye pressure and glaucoma later in life, called angle recession glaucoma. If there is no evidence of permanent structural damage within the eye after a blunt injury, the likelihood maybe lower, but I would still recommend lifelong periodic monitoring if someone has sustained an injury to the eye.

P: What about concussions and blows to the head or whiplash?

Dr. Anand Mantravadi: Severe whiplash injuries, concussions, and blows to the head usually involve aggressive forces at play. These can result in a number of intraocular injuries, from mild scratches on the surface of the eye (corneal abrasions), to severe injuries that may shear blood vessels, induce tears in the retina leading to detachments, or disrupt other structures in the eye such as the lens, iris, or angle.

P: If glaucoma develops immediately following the injury, can we assume the glaucoma will become more advanced and difficult to treat?

Dr. Anand Mantravadi: We can’t assume anything. It’s very difficult to generalize on trauma, and you are touching on the very basis for why studying traumatic injuries can be difficult in a randomized controlled fashion. Each injury mechanism can be different. Some glaucomas are recalcitrant to treatment, and others respond very well to treatment.

P: My glaucoma developed twenty-eight years after the trauma to my eye (which had me in the hospital for a week as the eye healed), but the trauma was still clearly identified as the cause. How common is that length of time between injury and development of glaucoma?

Dr. Anand Mantravadi: Angle recession glaucomas classically can occur decades following an injury. Smaller observational studies have shown that people can develop angle recession glaucoma more than thirty years following injury.

P: If trauma is to one eye and it develops glaucoma, will the other eye also develop glaucoma?

Dr. Anand Mantravadi: If trauma develops in one eye and it develops glaucoma, there is some thought that there is perhaps a structural/genetic predisposition to developing glaucoma, and perhaps the other eye is at a slightly higher risk of developing open angle glaucoma. However, this is not always the case, and certainly the recommendation is that any person, who has sustained traumatic glaucoma in one eye, should have lifelong monitoring for that eye, and also the non-injured eye.

P: What exactly does angle recession mean?

Dr. Anand Mantravadi: Angle recession is a tear between the longitudinal and circular muscles of the ciliary body. The ciliary body is the muscle within the eye that attaches into the angle. The exact reason for why people develop high pressures years after angle recession is speculative. There are suggestions that the injury might stimulate cellular and/or degenerative changes in the trabecular meshwork that leads to later chronic obstruction.

P: If there is a blow to the head that affects the “other end” of the optic nerve, the brain end, is it possible to develop glaucoma?

Dr. Anand Mantravadi: It is possible. A thorough eye exam can ascertain if there has been any intraocular structural damage that may predispose to glaucoma.

P: Is the incidence higher for blindness from traumatic glaucoma than from other forms of glaucoma?

Dr. Anand Mantravadi: I am not aware of the comparative statistics on traumatic glaucomas versus other forms. Traumatic glaucomas is a broad category that may also involve other structural intraocular injuries that may impact “blindness.”

P: Because the eye has been previously damaged, is the glaucoma that could develop from the damage more advanced than POAG (primary open angle glaucoma) or NTG (normal tension glaucoma)?

Dr. Anand Mantravadi: This is not necessarily the case. One reason is that perhaps particularly with angle recession glaucoma, where the pressure elevation and resultant glaucomatous damage happens many years after the injury, people may present to the physician at a later stage of glaucoma having not realized that disease can be a result of an event many years prior.

P: That is really interesting, doctor. I was diagnosed with JOAG five months ago at forty-two years of age. It is estimated that I have had glaucoma in my left for at least ten years. However, my vision is still 20/25. My right eye, meanwhile, barely is affected (although I still have glaucoma in the right eye). I have been in a few serious car accidents in my life (banged around but no long term hospitalization) but the doctor says my glaucoma is genetic. It was only recently discovered because I failed to go to the eye doctor for fourteen years! I know that is ridiculous. But would it be that obvious that it is genetic or traumatic if such a long period of time like that has passed?

Dr. Anand Mantravadi: The genetics of glaucoma can be complex, and it would be a challenge to identify any process that occurs in the body as being independent of genetics. Even a traumatic injury, where one person has traumatic glaucoma, another may not, perhaps because of the nature of the injury, or perhaps because one had a greater genetic predisposition to developing glaucoma with injury.

P: If one is diagnosed with traumatic glaucoma, is it more advisable to see a neuro-ophthalmolgist versus an ophthalmologist/glaucoma specialist?

Dr. Anand Mantravadi: Some traumatic glaucomas require a multidisciplinary approach. It’s hard to comment in general. Neuro-ophthalmology sub-specialists deal with specific forms of traumatic glaucomas, but are also trained in general ophthalmology as are glaucoma specialists/ophthalmologists.

P: Doctor, earlier you mentioned that thermal and/or chemical injury can lead to traumatic glaucoma. Can you list examples of each? Could stupidly, trying a synthetic drug in college, possibly lead to glaucoma?

Dr. Anand Mantravadi: Thermal means related to heat injury, i.e., burns, electrical, etc. Chemical means acute chemical exposures that can lead to acute or chronic sequela, such as acid or basic injuries, and environmental injuries.

P: Do airbag deployments in cars result in trauma to the eye?

Dr. Anand Mantravadi: They can. I’ve been involved with treating a few that have been related, but they also save lives!

Moderator: Dr. Mantravadi, thank you. It was a great discussion.

Dr. Anand Mantravadi: Thanks again everyone. I look forward to the next chat. Have a great evening.

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About the Author:

The Glaucoma Service Foundation’s mission is to preserve or enhance the health of all people with glaucoma and to provide a model of medical care by supporting the educational and research efforts of the physicians on the Wills Eye Institute Glaucoma Service, the largest glaucoma diagnosis and treatment center in the country.
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