Early Predictors of Traumatic Glaucoma After Closed Globe Injury Trabecular Pigmentation, Widened Angle Recess, and Higher Baseline Intraocular Pressure

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CLINICAL SCIENCES Early Predictors of Traumatic Glaucoma After Closed Globe Injury Trabecular Pigmentation, Widened Angle Recess, and Higher Baseline Intraocular Pressure

Ramanjit Sihota, MD, FRCS; Sunil Kumar, MD; Viney Gupta, MD; Tanuj Dada, MD; Seema Kashyap, MD; Rajpal Insan, MD; Geetha Srinivasan, MS

Objective: To prospectively analyze the clinical and ul- glaucoma showed evidence of cyclodialysis, compared trasonographic biomicroscopy (UBM) features in eyes with 7 eyes with glaucoma (P=.001). The relative risk with closed globe injury, at the initial examination, that of developing traumatic glaucoma was also significantly would predict the occurrence of chronic traumatic glau- higher with hyphema, elevated baseline IOP, angle re- coma during a 6-month follow-up. cession of more than 180°, lens displacement, and wider angles on UBM. Methods: Forty consecutive eyes with closed globe injury and a chronically elevated intraocular pressure (IOP) Conclusions: Clinically, the presence of increased pig- of at least 21 mm Hg for a minimum of 3 months were mentation at the angle, elevated baseline IOP, hy- diagnosed as having traumatic glaucoma and compared phema, lens displacement, and angle recession of more with 52 eyes with closed globe injury and no evidence than 180° were significantly associated with the occur- of glaucoma. rence of chronic glaucoma after closed globe injury. On UBM findings, a wider angle and the absence of cyclo- Results: The median grade of trabecular pigmentation dialysis were significant predictors for the subsequent de- on gonioscopy in eyes with traumatic glaucoma was 3 velopment of traumatic glaucoma. compared with 2 in eyes without glaucoma (P=.001). On UBM findings, 18 eyes with closed globe injury without Arch Ophthalmol. 2008;126(7):921-926

RAUMA IS A COMMON CAUSE damage such as angle recession. The aim of of ocular morbidity and oc- this study was to evaluate eyes prospec- curs most often during tively with closed globe injury from the ini- childhood or in young tial examination, to identify early ocular adults.1,2 Glaucoma after findings that could be significantly associ- Tclosed globe injury is a major concern be- ated with the development of a chronic trau- cause many cases may go unnoticed and, matic glaucoma, and to compare clinical and without close follow-up, are diagnosed ultrasonographic biomicroscopy (UBM) many years later as having irreversible findings in eyes that developed and did not glaucomatous optic nerve damage.3,4 Two develop chronic glaucoma. peak incidences of glaucoma after trauma have been reported, less then 1 year and METHODS at least 10 years after trauma.5 A 3.4% incidence of glaucoma after ocular contu- Consecutive patients initially seeking treat- sion has been reported during a 6-month ment in the ophthalmic casualty department follow-up6 and up to 10% during the 10 after concussive closed globe injury during a Author Affiliation: Glaucoma years after trauma.7 1-year period were included for evaluation. De- Research Facility and Clinical Retrospective studies have identified ocu- tails of the ocular injury—mode of injury, time Services (Drs Sihota, Kumar, lar features commonly seen in eyes with from trauma to initial visit, and route, dose, and Gupta, Dada, Insan, and traumatic glaucoma, such as poor baseline duration of therapy—were recorded. Prior ocu- Srinivasan) and Department of lar problems and a family history of glaucoma Ocular Pathology (Dr Kashyap), visual acuity, hyphema, an angle recession were also noted. Informed consent was ob- Dr Rajendra Prasad Centre for of more than 180°, traumatic cataracts, dis- tained from all patients in accordance with the 3,6 Ophthalmic Sciences, All India placement of the lens, and iris injuries. Declaration of Helsinki. Institute of Medical Sciences, However, only a few eyes develop glau- A thorough ocular examination of both New Delhi, India. coma, despite the presence of traumatic eyes was performed, including best corrected

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 diagnosed as having a traumatic glaucoma. In the absence of Table 1. Demographic Data of 92 Patients such a chronically elevated IOP or evidence of glaucomatous With Closed Globe Injury optic neuropathy, eyes were diagnosed as having only a closed globe injury without glaucoma. Closed Globe Histopathological evaluation of the trabeculectomy speci- Injury Without Traumatic mens was performed in eyes that underwent filtering surgery. Glaucoma Glaucoma We used SPSS statistical software, version 10.0 (SPSS Inc, Characteristic (n = 52) (n = 40) P Value Chicago, Illinois) for comparing the variables between glau- Age, mean (SD), y 22.4 (11.0) 19.4 (9.5) .74 comatous and control eyes. A binary logistic regression analy- Sex, No. M:F 49:3 37:3 .90 sis was used to determine the relative risk of developing glau- Trauma to presentation interval, 10.8 (15.1) 9.5 (5.9) .59 coma, as evidenced by baseline clinical features and UBM mean (SD), d findings. A PϽ.05 was considered statistically significant. Un- Type of trauma, No. (%) less otherwise indicated, data are expressed as mean (SD). Cricket ball 23 (44) 17 (43) .77 Firecracker 9 (17) 8 (20) .90 Wooden stick 10 (19) 7 (18) .85 RESULTS Other 10 (19) 8 (20) .88 We reviewed 121 eyes of 121 consecutive patients older than 10 years who had had a recent closed globe injury. visual acuity, slitlamp biomicroscopic examination, fundus Ninety-two patients fulfilled inclusion criteria for the study examination with a ϩ90-diopter lens, and indirect ophthal- after exclusion of 13 patients younger than 10 years, moscopy without indentation. Intraocular pressure (IOP) 5 with pseudophakia, and 1 who had undergone a re- measurements on at least 3 occasions were recorded by means cent vitreoretinal surgery. of applanation tonometry. The zone of injury was recorded Forty of the 92 patients (43%) had a persistent eleva- and classified according to the location.8 Zone 1 injuries were tion of IOP (Ն21 mm Hg) for at least 3 months, ie, trau- superficial injuries limited to the bulbar conjunctiva, sclera, matic glaucoma. The remaining 52 patients (57%) had or cornea, including corneal abrasion and subconjunctival an IOP consistently less than 21 mm Hg, with no evi- hemorrhage. Zone 2 injuries involved structures in the ante- dence of glaucomatous optic neuropathy; these patients rior segment up to and including the lens apparatus, the lens constituted the closed globe injury group. Demo- zonules, and the pars plicata. Zone 3 injuries were posterior injuries involving the pars plana, choroid, retina, vitreous, or graphic data are presented in Table 1. optic nerve. When we classified the closed globe injury group with- Patients older than 10 years who were cooperative during out glaucoma by the zone of injury, 22 (42%) had a zone the UBM and gonioscopic examinations were included in the 1 injury; 20 (38%) had a zone 2 injury; and 10 (19%) study. Exclusion criteria were an open globe injury, primary had a zone 3 injury. The respective numbers in the trau- glaucoma or other preexisting cause of secondary glaucoma, matic glaucoma group were 1 (3%), 21 (53%), and 18 and a history of ocular surgery or laser therapy. (45%) (P=.01). Four weeks after the trauma, gonioscopy with 360° gonio- Ocular findings are listed in Table 2. Hyphema, base- photography and UBM (UBM P-40; Paradigm Medical Indus- line IOP, trabecular pigmentation, angle recession, and tries, Salt Lake City, Utah) were performed by an experienced lens displacement were statistically more frequent in the glaucomatologist (V.G.) who was masked to the patient’s history and final diagnosis. On gonioscopic findings, the circum- traumatic glaucoma group. Four patients with trau- ferential extent of angle recession and cyclodialysis were noted matic glaucoma had a recurrence of bleeding within and pigmentation was graded as 0 (no pigmentation), 1 (faint), 5 days of the trauma, compared with none of the pa- 2 (average), 3 (heavy), or 4 (very heavy).6 tients with a closed globe injury. Ultrasonographic biomicroscopy images were obtained ra- A mean baseline IOP of 17.3 (5.0) mm Hg was re- dially every clock hour to find angle recession, cyclodialysis, corded in the closed globe injury group and 35.2 (12.8) iridodialysis, and lenticular subluxation or dislocation. The an- mm Hg in the traumatic glaucoma group (P=.001). Go- terior chamber depth, superior and inferior angle measure- nioscopic examination of the closed globe injury group ment in degrees, angle opening distance at 250 and 500 µm, revealed that 24 eyes had a normal angle structure. In and angle recess area were measured at the widest angle, with 1 eye, a cyclodialysis cleft was noted, associated with angle note of any other anterior segment abnormalities. All patients were followed up every month for 6 months and recession. Of the remaining 27 eyes, 22 had angle reces- as appropriate thereafter. At each visit, best corrected visual acu- sion of less than 180°; 3, of 180° to 270°; and 2, of more ity, applanation tonometry, and thorough anterior and poste- than 270°. On UBM examination, results showed that rior segment evaluations were performed. Humphrey field analy- 22 eyes had a normal angle; 23, an angle recession of less sis with a 30-2 SITA standard visual field (Humphrey Systems, than 180°; 5, an angle recession of 180° to 270°; Dublin, California) was recorded in patients with a best cor- and 2, an angle recession of more than 270° (Figure 1). rected visual acuity of more than 6/60. In the presence of a hy- In the traumatic glaucoma group, gonioscopic find- phema, patients underwent evaluation more frequently to moni- ings revealed that 3 eyes had normal angles, whereas 37 tor the IOP and corneal status. (93%) had varying degrees of angle recession. Thirteen All patients with concomitant posttraumatic uveitis were eyes had an angle recession of less than 180°; 9, of 180° treated with corticosteroids for a maximum of 2 weeks. For an elevated IOP, they were treated with ␤-blockers, brimonidine, to 270°; and 11, of more than 270°. In 4 eyes, gonio- or dorzolamide hydrochloride topically and systemic antiglau- scopic findings revealed a small cyclodialysis cleft asso- coma medications where necessary. ciated with angle recession. On UBM examination, 2 eyes Eyes with an elevated IOP (Ն21 mm Hg) and requiring glau- had a normal angle. An angle recession was detected in coma therapy for at least 3 months after closed globe injury were 31 eyes, including 8 with an angle recession of less than

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 2. Anterior and Posterior Segment Findings A in Eyes With Closed Globe Injury With and Without Chronic Glaucoma

Closed Globe Traumatic Injury Glaucoma (n=52) (n=40) P Value Visual acuity Ͻ6/60 at initial 12 (23) 25 (63) .001 examination, No (%) Mean (SD) baseline IOP, mm Hg 17.3 (5.0) 35.2 (12.8) .001 Anterior segment features B Hyphema 22 (42) 37 (93) .001 Sphincteric tears 18 (35) 17 (43) .44 Iridodialysis 4 (8) 6 (15) .43 Trabecular pigmentation grade Ն3 7 (13) 36 (90) Ͻ.001 Angle recession Ͼ180° 6 (12) 14 (35) .005 Angle recession of 360° 1 (2) 9 (23) .03 Cyclodialysis on UBM 18 (35) 7 (18) .001 Lenticular features Cataract 7 (13) 10 (25) .15 Phacodonesis 8 (15) 14 (35) .03 Posterior segment features Macular edema 11 (21) 12 (30) .33 C Choroidal rupture 4 (8) 5 (13) .67 Retinal dialysis 6 (12) 8 (20) .26 Vitreous hemorrhage 5 (10) 7 (18) .49 Macular hole 1 (2) 2 (5) .41

Abbreviations: IOP, intraocular pressure; UBM, ultrasonographic biomicroscopy. Figure 1. Gonioscopic appearance of an eye with traumatic glaucoma. aUnless otherwise indicated, data are expressed as number (percentage) A, Trabecular pigmentation of grade 4 with angle recession (arrow). B, Angle of eyes. recession with cyclodialysis (arrow pointing to the area of the beginning of cyclodialysis). C, Cyclodialysis with peripheral iris adhesions around the scleral spur (arrow). 180°; 10, of 180° to 270°; and 13, of more than 270°. In 7 eyes, a cyclodialysis cleft was detected on UBM examination (Figure 2), but the extent was less than 2 clock hours, and there was evidence of reattachment of the iris to the scleral spur in 5 eyes (Figure 3). We found good correlation between the extent of angle recession seen by means of gonioscopy and UBM (r2=0.66; PϽ.001). However, there was no significant correlation between cyclodialysis seen by means of gonioscopy and UBM (r2=0.16; P=.44.). 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) (PϽ.001). Trabecular pigmentation of at least grade 3 was seen in 7 eyes (13%) in the closed globe injury group and in 36 (90%) in the traumatic glaucoma group, correlating significantly with 2 Ͻ Figure 2. Results of ultrasonographic biomicroscopy of the anterior the presence of traumatic glaucoma (r =0.64; P .001). chamber angle showing the presence of cyclodialysis and an angle Trabecular pigment grades in 18 eyes with closed globe recession. The short arrow points to the scleral spur. Only sclera, with a cleft injuries and cleft were 4 in 1 eye, 3 in 5 eyes, and 2 or between it and the uveal tissue, is seen to the left of the scleral spur for a few less in 12 eyes. Thirty-three eyes had traumatic glau- millimeters (ie, the cyclodialysis). Further down, the long arrow points to a tear across the anterior face of the ciliary body, which is evidence of coma with no cleft, of which 15 had a trabecular pig- additional angle recession. mentation of grade 4; 13, of grade 3; and 5, of grade 2. The extent of pigmentation was not related to the extent of angle injury alone, but was also probably a result The relative risk of developing chronic glaucoma in of other ciliary body and iris damage. an eye with closed globe injury, based on clinical fea- On UBM, all 4 angle variables were found to be sig- tures seen at presentation, was greatest if there was heavy nificantly greater in patients with traumatic glaucoma pigmentation of the trabecular meshwork, an elevated compared with those with closed globe injuries (PϽ.001) baseline IOP, hyphema, angle recession, and lens dis- (Table 3). placement with a cataract (Table 4). Findings on UBM

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A B Table 4. Relative Risk of Developing a Chronic Glaucoma Based on Clinical and UBM Features of All Eyes After Closed Globe Injury

Features Seen Յ4wk Relative Risk After Injury (95% CI) P Value Trabecular pigmentation grade Ն3 20.8 (4.5-95.8) Ͻ.001 360° Angle recession 7.5 (1.9-28.8) .002 Hyphema 6.9 (2.3-20.6) .002 Lens displacement with cataract 3.5 (1.6-7.4) .005 Ͼ180° Angle recession 3.3 (2-5.25) .004 Visual acuity Ͻ6/60 2.5 (1.5-4) .01 Figure 3. Results of ultrasonographic biomicroscopy of the anterior chamber Baseline IOP 1.3 (1.1-1.5) .001 angle after trauma. A, An eye with a closed globe injury has a cyclodialysis (black arrow) and a widened suprachoroidal space. The peripheral iris has Lens displacement alone 1.7 (1.1-2.7) .02 fallen away from the spur, leading to a very wide angle and a large distance Postsegment involvement 1.4 (0.8-2.3) .34 from the scleral spur to the iris root (white arrow). B, Cyclodialysis as a UBM findings disinsertion of the ciliary body from the scleral spur (arrow), with adhesions Angle opening distance at 250 µm 42.4 (4.1-431) .002 between the peripheral iris and the area of the scleral spur. Angle recess area 30.3 (3.8-238) .001 Reattachment of the iris at the 18.7 (2.3-150) .006 scleral spur Table 3. Ultrasonographic Biomicroscopy Findings Angle opening distance at 500 µm 16.8 (2.8-99.5) .002 Anterior chamber depth 2.3 (0.7-7.5) .14 of the Anterior Chamber and Angle Structure in Eyes With Ͻ Closed Globe Injury With and Without Chronic Glaucomaa Presence of cyclodialysis 0.2 (0.1-0.5) .001

Abbreviations: CI, confidence interval; IOP, intraocular pressure; Closed UBM, ultrasonographic biomicroscopy. Globe Traumatic Injury Glaucoma Variables (n=52) (n=40) P Value Anterior chamber depth, mm 3.0 (0.4) 3.2 (0.4) .11 17 (P=.01). Six patients in the closed globe injury group Anterior chamber angle, degrees 28.9 (7.9) 33.7 (0.1) .004 and 2 in the traumatic glaucoma group were lost to fol- Angle recess area, mm2 0.5 (0.2) 0.8 (0.5) .003 Reattachment of the iris 0.4 (0.2) 0.6 (0.4) .008 low-up at 6 months. On follow-up, 7 patients in the trau- at the scleral spur, mm matic glaucoma group were found to have a retinal di- Angle opening distance alysis, compared with 6 patients in the closed globe injury At 250 µm 0.5 (0.2) 0.6 (0.3) .002 group. At 500 µm 0.6 (0.3) 0.8 (0.4) .002

a Data are expressed as mean (SD). COMMENT

Glaucoma after blunt trauma appears to have 2 peaks of of a large angle opening distance at 250 µm, an angle re- incidence, at less than 1 year and about 10 years after cession area, and a wider distance from the scleral spur trauma,5 by which time acute symptoms and signs of to the iris root also predicted chronic glaucoma. On the trauma have subsided and the patient is unaware of a other hand, the presence of a cyclodialysis was found to chronically elevated IOP. It is important to be able to iden- protect against the development of glaucoma (PϽ.001). tify eyes at risk for such a chronic traumatic glaucoma In the closed globe injury group, the mean IOP at the and to review them carefully, so that appropriate therapy 3-month follow-up was 16.2 (3.2) mm Hg and at 6 may be initiated as early as possible. months, 14.7 (3.8) mm Hg. In the traumatic glaucoma In our study, the anterior chamber angle was care- group, the mean IOP was 20.4 (4.1) mm Hg and 18.7 (4.8) fully studied by means of gonioscopy and recorded using mm Hg at 3 and 6 months, respectively. Only 5 patients 360° goniophotography. The presence of heavy trabec- in the closed globe injury group required 1 topical anti- ular pigmentation (grade Ն3) was a significant predic- glaucoma medication beyond 3 weeks, and all 5 pa- tor of chronic glaucoma, with a relative risk of 20.8. Ex- tients had ended therapy by 5 weeks after trauma. The tensive release of pigment into the eye during trauma mean number of topical medications at the start of therapy could clog the trabecular meshwork, and trabecular en- in the traumatic glaucoma group was 2.5 (1.2) and was dothelial cells that phagocytize the pigment particles could reduced to 1.2 (1.0) at 3 months and 1.1 (0.2) at 12 also block the meshwork, directly and through changes months. Eleven eyes in the traumatic glaucoma group re- induced at the meshwork.9 The degree of pigmentation quired trabeculectomy for control of IOP. Light micros- may be an indicator of the extent of anterior segment dam- copy of the trabeculectomy specimens confirmed the pres- age, but pigmentation of at least grade 3 was present in ence of heavy pigmentation. only 13% of eyes that did not develop a chronic glau- At the last follow-up in the closed injury group (mean, coma, although they also had severe disruption on the 12.0 [4.1] months; range, 9-18 months), 16 patients had anterior segment anatomy (eg, subluxation of the lens visual acuity of 6/6; 18 patients, of 6/9 to 6/60; and 10 and iris injury). The degree of trabecular pigmentation patients, of less than 6/60. In the traumatic glaucoma has been correlated with elevated IOP in other condi- group, the respective numbers of patients were 5, 16, and tions such as pigmentary glaucoma or pseudoexfolia-

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 tion and after the insertion of piggyback or sulcus- lens and vitreous. Earlier retrospective studies have re- fixated intraocular lenses.10-13 corded a frequent association of traumatic glaucoma with The baseline IOP of eyes developing chronic glau- poor baseline visual acuity, hyphema, an angle reces- coma was higher than that of eyes that did not, with a sion of more than 180°, traumatic cataracts, displace- range of 22 to 60 mm Hg compared with a range of 10 to ment of the lens, and iris injuries.3,6,7,16 However, in this 28 mm Hg. This has not been previously reported be- prospective study, we found the incidence of iris inju- cause most studies were retrospective. The elevated IOP ries and cataract to be comparable in eyes with trauma at baseline probably reflects decreased aqueous outflow alone and in those with traumatic glaucoma. due to extensive primary damage, inflammation, and pig- The features that were significantly associated with ment release at the trabecular meshwork. traumatic glaucoma—hyphema, an angle recession of We noted that a greater extent of angle recession re- more than 180°, displacement of the lens, and trabecu- sulted in a greater risk of traumatic glaucoma. Angle re- lar pigmentation—could all be attributed to ciliary body cession was present in 93% of the eyes in our traumatic damage. These ciliary body injuries would lead to an in- glaucoma group, but was also seen in 54% of those with- flammatory response not only at the site of injury, but out glaucoma. This suggests that there are additional fac- also throughout the ciliary body and in the contiguous tors involved that produce an elevation in IOP. Girkin et iris and trabecular meshwork. Resolution of uveal in- al6 reported an incidence of angle recession of 8.6% in eyes flammation and injury is generally by a fibroblastic re- without glaucoma and of 35.8% in eyes with glaucoma at sponse, as seen in the iris or the choroid. Such a repara- 6 months. This is much lower than our observations, as tive process in the ciliary body would necessarily involve is the 19% to 50% incidence previously recorded,14,15 with the adjoining trabecular meshwork, decreasing aque- incidence increasing in the presence of a hyphema.5 This ous outflow and raising IOP. may be because our study was designed to look for such A review of data from the US Eye Injury Register found changes, unlike the records reviewed retrospectively by increasing age, poor baseline visual acuity, angle reces- Girkin et al.6 Long-term studies of eyes having an angle sion, hyphema, and lens injury to be independent risk recession greater than 180° have shown that only 4% to factors for developing posttraumatic glaucoma.6 Post- 9% develop late chronic glaucoma.5,16,17 traumatic glaucoma was recorded at any time within 6 Ultrasonographic biomicroscopy allowed us to objec- months of the injury, based on the physicians’ opinion tively identify and delineate angle recession and other fea- alone. This last study, despite its large numbers, is lim- tures in traumatized eyes. A cyclodialysis was seen by us ited by the absence of standardized criteria for diagnos- in only 7 eyes with traumatic glaucoma (18%) and 18 of ing traumatic glaucoma. There are also limited data cited those without glaucoma (35%). The presence of a cyclo- on IOP, the time when glaucoma was diagnosed, the ex- dialysis was protective against the occurrence of chronic tent of angle recession, and the use of glaucoma therapy glaucoma on multivariate analysis. A cyclodialysis cleft in patients. results from disinsertion of longitudinal fibers of the cili- The higher prevalence of glaucoma after closed globe ary muscle from the scleral spur and underlying sclera, injury in our study patients was because our institution allowing direct communication between the anterior is a tertiary referral center and probably examines more chamber and ciliochoroidal space and unrestricted bulk severely traumatized eyes. A longer follow-up is neces- flow of aqueous from the anterior chamber to the supra- sary to see whether the IOP reduces with time or stays ciliary space. A cyclodialysis is usually associated with a elevated and to see whether eyes in the closed globe in- reduced IOP on initial examination, but IOP may injury group would develop glaucoma. crease spontaneously later with closure of the cyclodi- In conclusion, increased pigmentation of the angle alysis cleft. In some eyes, iris tissue blocks the cleft and on gonioscopic findings, a higher baseline IOP, and the prevents the development of hypotony. To the best of our absence of a cyclodialysis cleft on UBM or gonioscopic knowledge, no previous study has looked at the inci- findings, along with the previously described features of dence of cyclodialysis in the occurrence of or protection hyphema, angle recession, and lens injury, can assist in from traumatic glaucoma. the identification of eyes with closed globe injury, pre- Cyclodialysis was diagnosed by UBM findings and was disposed to chronic glaucoma. missed on gonioscopic findings in a large number of eyes. Cyclodialysis clefts may be difficult to detect in recently Submitted for Publication: September 5, 2007; final re- traumatized eyes because of the presence of hazy media, vision received November 29, 2007; accepted January 8, hypotony, a shallow anterior chamber, or an abnormal 2008. anterior segment architecture. Often, cyclodialysis clefts Correspondence: Viney Gupta, MD, Dr Rajendra Pra- are not apparent on gonioscopic findings, even if disrup- sad Centre for Ophthalmic Sciences, All India Institute tion of the anterior segment structures is minimal, be- of Medical Sciences, Ansari Nagar, New Delhi 110029, cause the placement of a gonioscope in a hypotonous eye India ([email protected]). causes a significant indentation of the central cornea, and Financial Disclosure: None reported. the convexity of the iris prevents visualization of the scleral 18 spur or the cyclodialysis cleft. Gentile et al also found REFERENCES UBM to have a greater sensitivity in detecting cyclodialysis after closed globe injury. 1. Salmon JF, Mermoud A, Ivey A, Swanevelder SA, Hoffman M. The detection of Blunt trauma displaces aqueous into the peripheral post-traumatic angle recession by gonioscopy in a population based glaucoma parts of the anterior chamber and posteriorly toward the survey. Ophthalmology. 1994;101(11):1844-1850.

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©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 2. Dandona L, Dandona R, Srinivas M, John RK, McCarty CA, Rao GN. Ocular trauma 10. Campbell DG, Schertzer RM. Pathophysiology of pigment dispersion syndrome in an urban population in southern India: the Andhra Pradesh Eye Disease Study. and pigmentary glaucoma. Curr Opin Ophthalmol. 1995;6(2):96-101. Clin Experiment Ophthalmol. 2000;28(5):350-356. 11. Richter CU, Richardson TM, Grant WM. Pigmentary dispersion syndrome and 3. Sihota R, Sood NN, Agarwal HC. Traumatic glaucoma. Acta Ophthalmol Scand. pigmentary glaucoma: a prospective study of the natural history. Arch Ophthalmol. 1995;73(3):252-254. 1986;104(2):211-215. 4. Sihota R, Sood NN, Agarwal HC. Juvenile secondary glaucomas in India. Indian 12. Shuba L, Nicolela MT, Rafuse PE. Correlation of capsular pseudoexfoliation ma- J Ophthalmol. 1991;39(3):94-96. terial and iridocorneal angle pigment with the severity of pseudoexfoliation 5. Blanton FM. Anterior angle recession and secondary glaucoma: a study of the glaucoma. J Glaucoma. 2007;16(1):94-97. aftereffects of traumatic hyphemas. Arch Ophthalmol. 1964;72:39-44. 13. Iwase T, Tanaka N. Elevated intraocular pressure in secondary piggyback intra- 6. Girkin CA, McGwin G Jr, Long C, Morris R, Kuhn F. Glaucoma after ocular con- ocular lens implantation. J Cataract Refract Surg. 2005;31(9):1821-1823. tusion: a cohort study of the United States eye injury registry. J Glaucoma. 2005; 14. Gracner B, Kurelac Z. Gonioscopic changes caused by blunt eyeball injuries in 14(6):470-473. sports [in German]. Klin Monatsbl Augenheilkd. 1985;186(2):128-130. 7. Kaufman JH, Tolpin DW. Glaucoma after traumatic angle recession: a ten-year 15. Filipe JA, Barros H, Castro-Correia J. Sports-related ocular injuries: a three-year prospective study. Am J Ophthalmol. 1974;78(4):648-654. follow-up study. Ophthalmology. 1997;104(2):313-318. 8. Kuhn F, Morris R, Witherspoon DC, Heimann K, Jeffers JB, Treister G. A stan- 16. Canavan YM, Archer DB. Anterior segment consequences of blunt ocular injury. dardized classification of ocular trauma. Ophthalmology. 1996;103(2):240- Br J Ophthalmol. 1982;66(9):549-555. 243. 17. Mooney D. Angle recession and secondary glaucoma. Br J Ophthalmol. 1973;57 9. Richardson TM, Hutchinson BT, Grant WM. The outflow tract in pigmentary glau- (8):608-612. coma: a light and electron microscopic study. Arch Ophthalmol. 1977;95(6): 18. Gentile RC, Pavlin CJ, Liebmann JM, et al. Diagnosis of traumatic cyclodialysis 1015-1025. by ultrasound biomicroscopy. Ophthalmic Surg Lasers. 1996;27(2):97-105.

Ophthalmological Numismatics

lthough Georg Prochaska (1749-1820) considered himself more of an anatomist than A an ophthalmologist, he nevertheless achieved recognition as one of the better eye sur- geons of his time, having performed no fewer than 3000 cataract operations. Born in Lipsitz (Moravia), he received his medical degree at the University of Vienna in 1776, where he returned in 1791 to serve as professor of anatomy, physiology, and ophthalmology after more than a decade in Prague as chair of anatomy. In Czechoslovakia in 1949, a commemorative medal by Jan Tomas Fischer 70 mm in di- ameter was struck in bronze for the bicentennial of Prochaska’s birth. The obverse depicts a clothed bust facing left surrounded by the words “GEORGIUS PROCHASKA MORAVUS 1749- 1820.” Within the curve at the lower right, it reads “FISCHER.” The reverse is inscribed in 4 parallel lines: “ARTIS MEDICAE/ NOVAM LUCEM ET/ FACIEM ELEGANTIOREM/ DABAT.” There is a floral design above and a staff of Aesculapius below, on either side of which reads “1749” and “1949.” Around the coin’s curve it reads “PROFESSOR PHYSIOLOGIAE ANATOMIAE MORB. OCULORUM UNIV. PRAGEN.”

Courtesy of: Jay M. Galst, MD, New York Medical College, and Peter van Alfen, PhD, American Numismatic Society. Correspondence: Dr Galst, 30 E 60th St, New York, NY 10022.

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