A 29-year-old amateur boxer attends for a routine eye check. Two years ago he had a hyphaema in the left eye after a sparring blow; the blood cleared with conservative care and his vision returned to normal. He has no symptoms today. He asks whether the old injury still matters.
Examination Findings
Visual acuity 6/6 both eyes. Left eye: quiet, no hyphaema remnant, pupil round. Intraocular pressure: right 15 mmHg, left 17 mmHg. Gonioscopy: angle recession over more than 180 degrees in the left eye — a widened ciliary body band with a torn iris root appearance; the right angle is normal. Optic discs healthy with symmetric cups, visual fields full, pachymetry normal.
Investigations
Gonioscopy is the diagnostic test — it reveals the torn ciliary body face that defines recession. Baseline optic disc imaging/photography, visual fields, and pachymetry-corrected pressure readings establish the reference for lifelong comparison. The fellow eye serves as the control.
Questions to Think About
- His pressure is normal and he feels fine. Why does he still need follow-up?
- What gonioscopic finding defines angle recession?
- What would prompt starting pressure-lowering treatment?
Diagnosis
Post-traumatic angle recession (>180°) without glaucoma, left eye; under long-term surveillance.
Reasoning
Reasoning: The old blow tore the ciliary body face, widening the angle — the classic recession. Aqueous outflow is impaired, but the remaining meshwork compensates for now; in a proportion of such eyes the pressure rises years or even decades later as the damaged meshwork fails. Normal pressure today is reassuring, not exonerating. Diagnosis: traumatic angle recession (>180°) without glaucoma, left eye — under surveillance. Management: typical management is structured long-term follow-up: periodic pressure checks, disc assessment, and visual fields, with the patient educated that the injury has a lifelong tail. Any sustained pressure rise or disc/field change triggers treatment per glaucoma protocols. He is strongly counselled on headgear and protective eyewear — the right eye is still at risk, and the left cannot afford a second blow.
Differential Diagnosis
- Traumatic angle recession without glaucoma — confirmed: classic gonioscopic appearance, normal pressure, healthy nerve — the surveillance diagnosis.
- Early angle-recession glaucoma — not yet: pressures normal and nerve/fields healthy, but this is what surveillance aims to catch.
- Pigment dispersion — distinguished: no Krukenberg spindle, no transillumination defects, clear traumatic history with recession on gonioscopy.
Management
Lifelong periodic review: intraocular pressure, optic disc, and visual fields. Treat promptly per glaucoma protocol if pressure rises or the nerve changes. Protective headgear/eyewear for boxing; the old injury is declared at every future eye examination.
Key Learning Points
- Angle recession is diagnosed on gonioscopy — a torn, widened ciliary body band — not on pressure readings.
- Normal pressure after hyphaema does not end the story; recession glaucoma can appear years later.
- Patients with recession need lifelong surveillance and must declare the old injury at every eye visit.
Red Flags
- Recession over 180° — the higher-risk group; never discharge these patients.
- Sustained pressure rise or disc/field change years later — angle-recession glaucoma has declared itself; treat.
- A second blunt injury to the same eye — compounds the damage; prevention is the treatment.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.