Cyclodialysis induced persistent hypotony: surgical management with vitrectomy and endotamponade

Ab Externo Choroidal Fluid Drainage, Pars Plana Vitrectomy, and Endotamponade for the Management of Persistent Hypotony following Glaucoma Surgery

Background

Persistent severe serous choroidal detachment is a rare complication after glaucoma surgery. Surgical treatment with choroidal fluid drainage through a scleral incision is an option in these cases. Combining this procedure with pars plana vitrectomy and gas endotamponade has potential advantages. In the following, the perioperative course of this surgical option in a small cohort will be presented.

Methods

This is a retrospective cohort study of the postoperative course of ab externo drainage of persistent serous choroidal detachment (≥4 weeks) in combination with pars plana vitrectomy and gas endotamponade in six eyes of six patients after exhausting all conservative treatment options. Inclusion criterion was persistent hypotony with severe serous choroidal detachment after intraocular pressure (IOP) lowering surgery due to medically uncontrolled glaucoma. Eyes were evaluated according to resolution of choroidal detachment, change in IOP and visual acuity (VA), postdrainage complications, and need for further surgeries.

Results

Before surgery, all patients presented with flat anterior chamber, decreased vision, and persistent choroidal detachment. The surgery itself was uneventful, but due to the complexity of the cases, tailoring the procedure to each patient's needs was required. Complete resolution of choroidal effusion was achieved by one month in 5 eyes and in 1 eye by month 3. There was an increase in average IOP from 5 (±2.1) mmHg before surgery to 11.3 (±3.7) mmHg and in VA from 1.7 (±0.8) to 1.2 (±0.6) logMAR. Five out of six patients required additional surgery, mainly to further increase the IOP even though choroidal detachment had already resolved.

Conclusion

Ab externo choroidal fluid drainage combined with pars plana vitrectomy and gas endotamponade seems to be an effective and safe treatment option in persistent ocular hypotony. Although repeated surgeries might be necessary, large-scale prospective studies must be undertaken to provide corroborative evidence.

Intrascleral sewing-machine technique: A Grooveless/flapless cyclopexy technique for large traumatic Cyclodialysis cleft repairs in pars plana vitrectomy

PURPOSE

To describe a minimally invasive technique for the repair of large traumatic cyclodialysis clefts using intrascleral sewing machine suture and overhand friction knot techniques in pars plana vitrectomy.

METHODS

This prospective, noncomparative, interventional case series included seven eyes of seven patients with a large traumatic cyclodialysis cleft. The sewing machine technique was modified by an intrascleral approach. The procedure was transconjunctival or subconjunctival performed without scleral flaps/grooves. An overhand friction knot was used to lead the cutting ends of the suture buried in the scleral tunnel.

RESULTS

The closure of the cyclodialysis cleft was achieved in seven eyes. The mean follow-up duration was 49.1 ± 15.6 weeks (range, 30-70 weeks). The intraocular pressure increased from 7.3 ± 2.1 mm Hg (range, 5-11 mmHg) preoperatively to 13.6 ± 2.4 mm Hg (range, 10-17 mmHg) postoperatively ( P < 0.01). The best-corrected visual acuity improved from a mean of 2.76 ± 2.77 logarithm of the minimum angle of resolution preoperatively to 0.63 ± 0.82 logarithm of the minimum angle of resolution at the final follow-up ( P < 0.01).

CONCLUSION

In conclusion, the present technique is safe and effective in the treatment of large traumatic cyclodialysis clefts with minimal surgical trauma and a decreased surgical duration.

COMPARING VITRECTOMY, SILICONE OIL ENDOTAMPONADE WITH/WITHOUT CYCLOPEXY TO TREAT CYCLODIALYSIS CLEFTS WITH SEVERE OCULAR TRAUMA

PURPOSE

Comparing the anatomical and functional outcomes of vitrectomy, silicone oil endotamponade without cyclopexy (VEWOC) and with cyclopexy (VEWC) in patients with traumatic cyclodialysis clefts and severe ocular comorbidities.

METHODS

A total of 55 patients (55 eyes) with traumatic cyclodialysis clefts were divided into VEWOC and VEWC groups according to the surgery undergone. Besides the cyclodialysis clefts, all study eyes had one or more additional conditions caused by severe ocular trauma: cataract, lens dislocation, vitreous hemorrhage, retinal detachment, choroidal detachment, maculopathy, suprachoroidal hemorrhage, subretinal hemorrhage, or proliferative vitreoretinopathy. The minimum postoperative follow-up period for all patients was six months. The main measures of outcome were rate of successful anatomical repair, intraocular pressure, and best-corrected visual acuity.

RESULTS

Both the VEWOC group (33 eyes) and the VEWC group (22 eyes) showed significant improvement in postoperative best-corrected visual acuity and intraocular pressure at the final follow-up. The groups had no significant differences in terms of anatomical success rates (VEWOC 29/33 vs. VEWC 20/22, P = 1.000), final best-corrected visual acuity (VEWOC 1.60 ± 0.76 [median Snellen acuity: counting fingers, range: light perception to 20/20] vs. VEWC 1.46 ± 0.66 [median Snellen acuity: 20/800, range: light perception to 20/32], P = 0.485), and final intraocular pressure (VEWOC 13.40 [8.20-17.80] vs. VEWC 11.40 [6.65-14.00] mmHg, P = 0.311). However, the intraocular pressure on postoperative Day 1 was significantly different between the groups (VEWOC 10.40 [6.40-14.60] vs. VEWC 6.40 [4.70-7.98] mmHg, P = 0.002).

CONCLUSION

This study showed that both surgical approaches were equally effective in treating cyclodialysis clefts secondary to severe ocular trauma. Therefore, it may be unnecessary to perform cyclopexy in addition to the vitrectomy procedure in such cases.

Vitrectomy with Air Endotamponade for Traumatic Cyclodialysis

Background

Various techniques have been described for repairing cyclodialysis clefts, but there is no consensus regarding the optimal treatment. This study investigated the clinical efficacy of a novel surgical approach that is used to manage traumatic cyclodialysis.

Methods

We prospectively enrolled 7 patients (7 eyes) with traumatic cyclodialysis of the concomitant lens and other vitreous diseases. Ultrasound biomicroscopy was used to diagnose cyclodialysis, and all eyes underwent pars plana vitrectomy with air endotamponade. The main outcome measures were postoperative anatomical success rates, best-corrected visual acuity (BCVA), and intraocular pressure (IOP).

Results

All patients were male, and their age ranged from 46 to 64 years (mean: 54.3 years). After the surgical intervention, the extent of the cyclodialysis cleft ranged from 1 to 4 clock hours (mean: 2.3 clock hours) and the detached ciliary body of all cases was completely restored; the anatomical success rate was 100%. The BCVA significantly increased from 1.40 ± 0.49 to 0.42 ± 0.31 (P = 0.002). The IOP increased from 8.91 ± 1.77 to 14.67 ± 6.38, but the difference was not significant (P = 0.056). The postoperative IOP of most patients was temporarily elevated or lowered after surgery. At the last follow-up, there were still two abnormal cases, including one with ocular hypertension and one with hypotony.

Conclusions

This study revealed that vitrectomy with air endotamponade is an effective and minimally invasive alternative surgical approach for small traumatic cyclodialysis clefts.

Ciliary body suturing using intraocular irrigation for traumatic cyclodialysis: two case reports

Background

We report two cases (two eyes) of traumatic cyclodialysis with prolonged decrease of intraocular pressure that were successfully treated with surgery by ciliary body suturing using intraocular irrigation.

Case presentation

This study involved a 17-year-old Japanese boy (patient 1) and a 31-year-old Japanese man (patient 2) in whom cyclodialysis was sustained in one eye after blunt-force ocular trauma from a thrown ball. Because the hypotony maculopathy in both patients did not resolve after conservative treatment, ciliary body suturing was performed. Briefly, a 25-gauge trocar intraocular irrigation needle for vitrectomy was inserted into the vitreous cavity of the injured eye. A lamellar scleral flap was then made, and an incision was created on the sclera while maintaining intraocular pressure. Next, the detached ciliary body was sutured to the sclera under direct vision. The intraocular fluid at the site of cyclodialysis was then rapidly drained from the scleral wound because of elevated intraocular pressure in the vitreous cavity, and the ciliary body was visually recognized through the scleral wound under direct vision, thus allowing a stable suture fixation of the ciliary body to the sclera. Postoperatively, the treated eye in both cases showed improvement of intraocular pressure and visual function.

Conclusions

The surgical method described in this report was found to be effective for draining intraocular fluid at the site of cyclodialysis and for performing a stable suture fixation of the ciliary body to the sclera through the scleral wound under direct vision, and it should be considered advantageous for avoiding intraoperative bleeding and suturing in a blinded manner.

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.

Continuous ab interno repairing of traumatic cyclodialysis cleft using a 30-gauge needle in severe ocular trauma: a clinical observation

Background

To investigate the efficacy and safety of continuous ab interno repairing of traumatic cyclodialysis cleft in severe ocular trauma using a 30-gauge (G) needle.

Methods

Fifteen patients (15 eyes) with traumatic cyclodialysis cleft admitted to the ocular trauma department of our hospital from July 2014 to December 2018 were included in this study. After the bulbar conjunctiva corresponding to the ciliary body was incised along the corneal limbus, an incision was made along the corneal limbus on the opposite side. A 30G needle with a 10–0 suture entered the anterior chamber from the incision and passed through the ciliary body with clefts and the sclera to fixate the ciliary body on the sclera wall with continuous mattress suture. The best corrected visual acuity (BCVA) and intraocular pressure (IOP) were observed preoperatively and postoperatively. In vivo ultrasound biomicroscopy (UBM) was performed to observe closure of cyclodialysis cleft before and after surgery.

Results

Fifteen patients successfully underwent continuous mattress suture for repair of cyclodialysis cleft. No bleeding and suture breakage were reported during surgery. After surgery, the UBM during follow-up showed satisfactory closure of the cyclodialysis cleft. The BCVA and IOP were improved to different degrees. The difference between the preoperative IOP and the postoperative IOP (1 week) was statistically significant (preoperative: 6.49 ± 0.98 mmHg, postoperative: 16.17 ± 4.65 mmHg, t = − 8.43, P < 0.05), and the difference between the preoperative IOP and the postoperative IOP (1 month) was also statistically significant (preoperative: 6.49 ± 0.98 mmHg, postoperative: 14.63 ± 3.63 mmHg, t = − 8.38, P < 0.05). Duration of outpatient follow-up was 3 to 12 months. No complications, including exposed knots, loose sutures, decompensation of corneal endothelium, sympathetic ophthalmia, endophthalmitis and choroidal detachment, were reported.

Conclusion

Continuous ab interno repairing of traumatic cyclodialysis cleft in severe ocular trauma using a 30G needle is a safe and effective procedure with simple operation, little tissue damage and few complications.

Encircling Scleral Buckling for Traumatic Severe Hypotony

The authors report the use of an encircling scleral buckling procedure for the management of severe hypotony secondary to traumatic annular ciliochoroidal detachment (CCD) with cyclodialysis cleft. Medical records of patients with severe ocular hypotony were retrospectively reviewed. Four patients with traumatic annular CCD with cyclodialysis cleft were identified. Diagnosis of CCD was documented by ultrasound biomicroscopy and presence of cyclodialysis cleft was confirmed by gonioscopy or ultrasound biomicroscopy. All patients underwent scleral buckling surgery with an encircling band for annular CCD with cyclodialysis cleft. Intraocular pressure (IOP) and visual acuity (VA) significantly improved postoperatively. Mean IOP changed from 2.5 mm Hg ± 0.5 mm Hg to 10.75 mm Hg ± 1.1 mm Hg (P = .0129) and mean best-corrected VA changed from +0.50 ± 0.16 logMAR to +0.15 ± 0.17 logMAR (P = .0123). IOP normalization was achieved despite persistence of CCD. These results support the use of scleral buckling with an encircling band as an effective approach for severe hypotony in patients with annular CCD regardless the cyclodialysis cleft extension. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:58-63.].

Cyclodialysis: an updated approach to surgical strategies

Cyclodialysis is a rare occurrence and is difficult to treat, it being concealed behind the iris. In view of the varied success outcomes of the different available surgical repair techniques, there is at present no clear consensus regarding their management strategies. Through this article, we intend to appraise the established surgical methods, update the novel techniques in vogue, discuss their outcomes and propose a uniform system to codify these corrective techniques. They have been reclassified under the terms 'exocyclopexy', 'endocyclopexy', 'exocyclotamponade' and 'endocyclotamponade' based on the approach used and their mode of action. The ab-interno techniques (endocyclopexy and endocyclotamponade) are easier to perform, offer good success rates and better safety profiles such that they may be considered as a viable alternative to the standard exocyclopexy in either cataractous or pseudophakic and aphakic eyes.

[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.

Novel surgical management of cyclodialysis cleft via anterior chamber perfusion: Case report

RATIONALE

Cyclodialysis cleft is a relatively rare but severe condition with persistent ocular hypotony, which can cause morphologic changes and visual loss. Here we report a case of a traumatic cyclodialysis cleft that was successfully managed with direct cyclopexy via anterior chamber perfusion. During the operation, if there is aqueous humor flowing out of the deep scleral incision, the cleft is not closed, and surgery should continue until there is no aqueous outflow.

PATIENT CONCERNS

A 66-year-old man was treated for severe blunt ocular trauma of the left eye and a resultant cyclodialysis cleft, lens subluxation, choroidal detachment and a cataract. His intraocular pressure was 6 mm Hg, he presented with a shallow anterior chamber, phacodonesis, iridodonesis, 360° ciliary body detachment, and a suspicious cyclodialysis cleft in the 5 to 8 o'clock position. DIAGNOSES:: ocular blunt trauma (left eye), cyclodialysis cleft (left eye), lens subluxation (left eye), choroidal detachment (left eye), cataract (both eyes).

INTERVENTIONS

The cataract was extracted by phacoemulsification and a posterior chamber intraocular lens was implanted with 2 capsular tension rings, one in the lens bag and the other in the ciliary sulcus. Throughout the following month, intraocular pressure fluctuated between 4 and 6 mm Hg and the ciliary body failed to reattach. A cyclopexy via anterior chamber perfusion was thus deemed necessary and performed.

OUTCOMES

After cyclopexy, intraocular pressure increased to 27 mm Hg and decreased to 16 mm Hg after brinzolamide eye drops treatment twice daily for 4 days. Subsequently intraocular pressure stabilized between 10 to 21mm Hg. Complete closure of the cyclodialysis cleft was confirmed with ultrasound biomicroscopy.

LESSONS

Cyclopexy via anterior chamber perfusion for patients with cyclodialysis cleft is a simple, safe, and efficient technique that ensures a successful surgery.