Traumatic Glaucoma

How eye injury raises pressure

Traumatic glaucoma is one of the possible long-term results of eye trauma. Like other forms of glaucoma, it damages the optic nerve.

The eye constantly makes fluid (aqueous humor) that drains out through the trabecular meshwork in the angle between the iris and cornea. Pressure rises when this drainage is blocked or damaged.

Early (acute) causes

• hyphema: blood in the front chamber clogs the drainage meshwork. Pressure rises especially if bleeding recurs, typically 2 to 5 days after injury
• inflammation (traumatic iritis): swelling and debris block drainage
• lens damage: a dislocated lens can block the pupil, a traumatic cataract can swell, and a ruptured lens can release proteins that clog the meshwork
• swelling of the ciliary body pushing the iris forward
• chemical injuries

Late (chronic) causes

• angle recession: blunt trauma tears the ciliary body muscle and drainage tissue. Over months to years, scarring reduces outflow. The risk of glaucoma is highest when a large portion of the angle is recessed
• peripheral anterior synechiae: scar tissue sealing the iris to the cornea
• ghost cell glaucoma: old red blood cells after vitreous bleeding block drainage
• long-term steroid drop use after injury

Who is at higher risk

• large hyphemas, especially filling half or more of the front chamber
• rebleeding
• sickle cell disease or trait: red cells sickle in the eye, blocking drainage more easily and harming the optic nerve at lower pressures
• extensive angle recession
• pre-existing glaucoma or family history of glaucoma

Symptoms

Early

• eye pain and headache
• blurred vision
• redness
• light sensitivity
• nausea and vomiting with very high pressure
• visible blood in the eye

Late

• often no symptoms until damage is advanced
• gradual loss of side vision in the injured eye

Diagnosis

• eye pressure measurement
• slit lamp examination for blood, inflammation and lens position
• gonioscopy to view the drainage angle and assess angle recession, done once acute bleeding has settled
• dilated examination of the optic nerve and retina
• visual field testing and OCT of the optic nerve
• sickle cell screening in people with hyphema and relevant ancestry
• imaging (CT or ultrasound) if the eye wall may be ruptured

Treatment

Acute hyphema and early pressure rise

• rest with the head raised about 30 to 45 degrees
• an eye shield
• steroid and dilating (cycloplegic) drops to reduce inflammation and pain
• pressure-lowering drops (beta blockers, alpha agonists, carbonic anhydrase inhibitors) and sometimes oral medicines
• avoid aspirin and NSAIDs, which increase rebleeding risk. Use acetaminophen (paracetamol) for pain
• surgical washout of blood if pressure stays very high or the cornea becomes stained

In sickle cell disease or trait, some pressure-lowering medicines such as carbonic anhydrase inhibitors are used cautiously, and surgery is considered at lower pressure thresholds.

Chronic traumatic glaucoma

• pressure-lowering drops
• laser treatment, though it is less effective in angle recession than in other glaucomas
• surgery: trabeculectomy or glaucoma drainage devices when drops are not enough

Prevention

• wear protective eyewear for sports such as racquetball, squash, hockey, baseball and paintball
• use safety glasses at work and for yard work and DIY
• use proper seatbelts in vehicles
• after any significant eye injury, keep up yearly eye exams for life, even if your vision seems fine

Outlook

With early detection and treatment, many people keep good vision. Untreated traumatic glaucoma can lead to permanent vision loss in the injured eye. Late angle-recession glaucoma can appear decades after injury, so ongoing monitoring is important.

Frequently asked questions

What is traumatic glaucoma?

Traumatic glaucoma is optic nerve damage from raised eye pressure caused by an eye injury. It can occur soon after the injury, from bleeding or inflammation, or years later from scarring of the eye's drainage system.

Can a blow to the eye cause glaucoma years later?

Yes. A blunt injury can tear the eye's drainage angle (angle recession). Scarring can slowly raise eye pressure and cause glaucoma months to decades later, often without symptoms. Yearly eye exams are recommended after a significant injury.

What is a hyphema?

A hyphema is bleeding into the front chamber of the eye, between the cornea and iris, usually after blunt trauma. It can raise eye pressure and needs urgent eye care. Rebleeding in the first days is a particular risk.

How is traumatic glaucoma treated?

Treatment includes pressure-lowering eye drops, steroid and dilating drops for inflammation, and laser or surgery when pressure cannot be controlled. A hyphema may need surgical washout if pressure stays high.

Why does sickle cell matter after an eye injury?

In sickle cell disease or trait, red blood cells in a hyphema can sickle and block the eye's drainage more easily, raising pressure. The optic nerve is also more vulnerable, so treatment is more aggressive and some medicines are avoided.