Management of cyclodialysis cleft associated to hypotonic maculopathy

Spontaneous Closure of Cyclodialysis Cleft in a Case of Normal-Tension Glaucoma Post Ab-Interno Trabeculotomy

A cyclodialysis cleft (CDC) is the detachment of longitudinal ciliary muscle from scleral spur, causing an unusual communication between anterior chamber and suprachoroidal space, resulting in possible hypotony. We report a case of a 63-year-old woman with normal-tension glaucoma (NTG), who developed a shallow anterior chamber with relatively low intraocular pressure (IOP, 6-8 mmHg) after combined ab-interno trabeculotomy and phacoemulsification. Her vision reached good (20/20) with the mild myopic shift. After detecting subtle signs of clinical hypotony, CDC was confirmed and monitored using anterior segment optical coherence tomography. Five months after surgery, she encountered an episode of eye pain, with transient IOP elevation and deepening of the anterior chamber. Spontaneous closure of CDC was suspected and confirmed gonioscopically.

To the best of our knowledge, this is the first case to describe the clinical course of spontaneous CDC closure in a patient with NTG after ab-interno trabeculotomy. It is advisable to inform the patient about potential IOP spike after spontaneous closure once CDC is diagnosed.

Intraocular endoscopy for the evaluation and treatment of hypotony due to a traumatic cyclodialysis: a case report

Background

A cyclodialysis cleft often leads to direct communication between the anterior chamber and the suprachoroidal space. It is a rare condition that is encountered with blunt trauma, and less commonly, after surgery. Hypotony is the major sequelae that may lead to hypotonous maculopathy, optic disc edema, corneal folds, and astigmatism. These may cumulatively lead to visual loss. We describe how endoscopy in a cyclodialysis repair allowed us to accurately locate the cleft and guided its appropriate management avoiding unnecessary cryopexy.

Case presentation

A 41-year-old male experienced a traumatic cyclodialysis cleft, which resulted in persistent hypotony. Pars plana vitrectomy was performed to treat vitreous hemorrhage. Scleral indentation was attempted to visualize the cyclodialysis cleft. However, the depression distorted the visualization. Intraocular endoscopy was therefore used to evaluate the cleft. Guided by this assessment, only intraocular gas tamponade was used to reposition the ciliary body. The patient’s intraocular pressure was restored to 13 mmHg 3 days after the operation, and OCT confirmed cleft closure 1 month after the operation.

Conclusion

Endoscopy-assisted repair of cyclodialysis is an approach that enhances visualization and can guard against common causes of persistent cleft and hypotony, as well as reveal the causes of recurrent failure. Hence, it can eliminate unnecessary cryopexy that might worsen the hypotonous state. In our case, intraocular endoscopy was effective for the evaluation of a cyclodialysis cleft and the subsequent selection of an appropriate management technique, gas tamponade, that was more conservative than other approaches initially considered.

[Cyclodialysis, a therapeutic challenge: Review of the literature on current practices]

INTRODUCTION

Cyclodialysis is a rare condition that is difficult to manage. We present the case of a woman with a cyclodialysis complicated by chronic hypotony requiring two surgeries to achieve reattachment of the ciliary body. We also report the results of a review of the literature regarding the treatment of this condition.

DESCRIPTION

This is a 46-year-old woman with history of trauma to the right eye. Examination revealed an intra-ocular pressure (IOP) of 7mmHg, a shallow anterior chamber and signs of chronic hypotony on fundus examination (vascular tortuosity, hypotony maculopathy) due to an extensive 360° cyclodialysis, confirmed by ultrasound biomicroscopy. Transcleral cryotherapy as a first-line approach did not achieve reattachment of the ciliary body. Secondary pars plana vitrectomy with gas tamponade (C2F6) reattached the ciliary body and restored the intraocular pressure (12mmHg) and normal fundus appearance. The patient recovered corrected visual acuity of 20/20.

DISCUSSION

To our knowledge, there is no standardized management for cyclodialysis. The study of the literature available on the Medline database showed that direct cyclopexy remains the most common treatment, followed by vitrectomy with internal tamponade. Neither the extent nor the duration of the cyclodialysis can predict the visual recovery, which can be major even after weeks of hypotony.

CONCLUSION

The management of cyclodialysis is not well-defined; it remains a true therapeutic challenge.

Internal cyclopexy for complicated traumatic cyclodialysis cleft

PURPOSE

To assess the surgical and functional outcome of internal direct cyclopexy as therapy of complicated traumatic cyclodialysis.

METHODS

The single-centre interventional case-series study included eyes with traumatic cyclodialysis who had consecutively been treated. Internal cyclopexy was performed using double-armed sutures introduced into the eye through the pars plana opposite to the cyclodialysis cleft and which were laid parallel to limbus. Additional procedures included cataract surgery, and pars plana vitrectomy. The cyclodialysis was documented upon ultrasound biomicroscopy and gonioscopy.

RESULTS

The study included 44 patients (44 eyes). The cyclodialysis extended over 4.8 ± 3.2 clock hours of scleral spur circumference (range 1-12 hr, median 4 hr), involving >180° of the scleral spur circumference in 16 eyes (37%) and 360° in 3 eyes (7%). Besides cyclodialysis, additional trauma-related complications included hyphema, iridodialysis, lens dislocation, cataract, vitreous haemorrhage, retinal detachment, suprachoroidal haemorrhage and endophthalmitis. The surgery performed on average at 64 days after the trauma included a mean number of 4.6 ± 1.9 sutures (range: 2-9), with 1.2 sutures per 30° width of cyclodialysis. Mean follow-up was 32 ± 8 weeks (range: 6-51 weeks). Closure of the cyclodialysis was achieved in all 44 eyes, and intraocular pressure (IOP) increased from 8.0 ± 3.4 mmHg (range: 3 21 mmHg) to 14.4 ± 4.0 mmHg (range: 11-21 mmHg). Mean visual acuity (VA) improved from 2.3 ± 1.1 logMAR (range: 0.22-4.0) to 1.2 ± 0.8 logMAR (range 0.3-4.0 logMAR).

CONCLUSION

In conclusion, internal direct cyclopexy is a novel and relatively little invasive surgery technique for the repair of traumatic cyclodialysis.