Ocular hypotony: a review

The etiology, diagnosis, sequelae, and management of ocular hypotony are discussed in this review. Hypotony from decreased production of aqueous is often due to inflammation, medications, or proliferative vitreoretinopathy. Hypotony from aqueous loss may be external, such as following surgery or trauma, or internal, as in cyclodialysis cleft or retinal detachment. Treatment of hypotony is most effective if the underlying cause can be addressed, either surgically or medically. Marked improvement in vision may be achieved if hypotony is reversed.

Management of hypotony after trabeculectomy with mitomycin C

The purpose of this study was to determine the incidence and risk factors of hypotony and the effectiveness of medical and surgical treatment. A total 117 eyes of 103 patients that underwent trabeculectomy with mitimycin C (MMC) between 1993 and 2000 were reviewed. Hypotony was treated with the following methods in a stepwise manner: medical treatment, intrableb autologous blood injection, additional sutures to the scleral flap, necrotic bleb excision and advancement of the forniceal conjunctival flap. Hypotony developed in 30 eyes (25.6%) of 26 patients, among, which hypotonic maculopathy developed in 11 eyes (9.4%). The risk factors of hypotony were young age and primary open angle glaucoma. Because of no light sense, 6 of the 30 hypotonic eyes were not treated. Nineteen (79.2%) of the 24 treated hypotonic eyes were successfully managed. Five eyes, 3 with hypotony but maintaining visual acuity and 2 with follow-up loss, were not included in the success group. The mean intraocular pressure (IOP) before treatment, 2.5 +/- 1.2 mmHg, increased to 8.3 +/- 4.0 mmHg at 18.5 months follow-up. The stepwise treatment seems to be a useful method to manage hypotony after trabeculectomy with MMC.

Severe hypotony after macular translocation surgery with 360-degree retinotomy

PURPOSE

To report a case of severe hypotony after macular translocation with 360-degree retinotomy.

DESIGN

Interventional case report.

METHODS

A 50-year-old woman with myopic neovascular maculopathy underwent macular translocation with 360-degree retinotomy in her left eye.

RESULTS

After the second procedure of silicone oil removal, severe hypotony developed. No clear sign of leakage was found. Pure perfluoropropane gas tamponade was then performed, which resulted in temporal resolution of severe hypotony, but the hypotony recurred as the gas bubble was absorbed. Ten weeks after the second surgery, the hypotonous eye was refilled with silicone oil. No apparent cyclitic membrane was observed intraoperatively. After this procedure, the choroidal and retinal folds regressed; intraocular pressure has been between 5 and 7 mm Hg for more than 4 months thereafter.

CONCLUSION

Severe hypotony can occur as a complication of otherwise uneventful macular translocation with 360-degree retinotomy.

[Autologous blood injections for treating hypotonies after trabeculectomy]

The authors carried out a retrospective study in order to assess the efficacy of intrabled autologous blood injections after trabeculectomy. The indication for treatment was hypotony associated with overfiltration. Twelve eyes of 12 patients including seven men (58.3%) and five women (41.67 %) underwent from one to four (mean 1.7) subconjunctival injections. The age of the patients ranged from 31 to 66 years (mean 52.4 years). All the patients were diagnosed with open-angle glaucoma. Three eyes underwent trabeculectomy with mitomycine C, one with 5-fluorouracil and eight with no antimetabolite. The mean post-needling period was 12.3 months (ranging from 7 to 28 months). After intrabled blood injections, the average intraocular pressure increased from 2.7 1.2 mmHg (ranging from 0 to 6 mmHg) to 8.2 4.2 mmHg (ranging from 4 to 16 mmHg). The difference was statistically significant (P < 0.5). After treatment, the average visual acuity increased from 1.8/10 to 3.2/10. This difference was not statistically significant (P > 0.5). However, the procedure was ineffective in two patients (16.7%) as regards intraocular pressure and in seven patients (58.3%) as regards visual acuity. Hyphema, the most frequent complication (58.3% of our cases) is usually small, transient, and without sequelae. Although it may be delayed, it may be important and it induce intraocular hypertony (10% of our cases) or it may be associated with intravital blood.

Autologous blood injection for marked overfiltration early after trabeculectomy with mitomycin C

PURPOSE

After trabeculectomy with mitomycin C, extremely low intraocular pressure (IOP) with excess filtration may cause hypotonous maculopathy in the early postoperative period. We evaluated the effect of injecting autologous blood on reversing early postoperative marked hypotony after trabeculectomy with mitomycin C.

METHODS

Trabeculectomy with mitomycin C was performed in 258 eyes between 1994 and 1998. Peribleb autologous blood injection was performed in five eyes in which pressure patches were ineffective in reversing excess filtration. Approximately 0.1 to 0.3 ml of whole unclotted blood was slowly injected at least 3 mm from the edge of the flap using a sterile 27-gauge needle.

RESULTS

None of these eyes developed hypotonous maculopathy after injection. After a mean 31-month follow-up, all eyes had well-controlled IOP and visual acuity in three eyes was much improved. Postoperative complications included mild IOP elevation in one eye treated with laser suturelysis, and fibrinous pupillary membrane in one eye.

CONCLUSION

In the early postoperative period, autologous blood injection is effective in reversing excess filtration.

[Administration of autologous blood to a patient via intrableb injection as a method for treating hypotony after trabeculectomy]

Hypotony is a common complication of glaucoma filtering surgery. The aim of this paper is to evaluate the treatment of this complication by intrableb injection of autologous blood. This procedure was performed in 9 patients with hypotony after trabeculectomy. Normalization of intraocular pressure was noted in 8 patients. No complications were observed. Intrableb injection of autologous blood can be used as an effective method in the treatment of hypotony following filtration surgery.

Treatment of hyperfiltering blebs with Nd:YAG laser-induced subconjunctival bleeding

PURPOSE

To assess the feasibility of a new technique to manage hyperfiltering blebs after penetrating glaucoma surgery.

METHODS

Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser bursts were used to induce bleeding in conjunctival and episcleral vessels in the bleb area to achieve local delivery of autologous blood.

RESULTS

In the three cases reported here in which this technique was used, the treatment was successful and safe, leading to resolution of hypotony and reduction of the bleb with no complications.

CONCLUSION

Subconjunctival bleeding can be achieved using Nd:YAG laser, and can represent a valuable alternative to autologous blood injection in cases of hyperfiltration after glaucoma surgery.

Combination of autologous blood injection and bleb compression sutures to treat hypotony maculopathy

PURPOSE

To report successful use of a combination of autologous blood injection and bleb compression sutures to treat overfiltration with hypotony maculopathy after trabeculectomy with mitomycin C.

METHODS

Two patients underwent the combined procedure and were followed until visual acuity and intraocular pressure (IOP) were stable over three consecutive visits (4 to 9 months).

RESULTS

Both patients experienced improvement in visual acuity both subjectively and objectively, and both patients had an elevation in IOP that persisted over three consecutive visits.

CONCLUSIONS

Combination autologous blood injection and bleb compression suture placement may be an effective means of treating hypotony maculopathy after trabeculectomy with mitomycin C.

Intravitreal gas injection for hypotony after cataract surgery

PURPOSE

To evaluate the efficacy and safety of intravitreal perfluoropropane gas injection to treat hypotony after cataract surgery.

SETTING

The ophthalmology department of a major tertiary medical center.

METHODS

After uneventful cataract extraction, 5 patients with hypotony due to iridocyclitis, choroidal detachment, and serous retinal detachment were treated with an intravitreal injection of 1.0 cc of perfluoropropane gas.

RESULTS

The hypotony, choroidal detachment, and exudative retinal detachment resolved in all 5 patients, and visual acuity improved. No complications were observed.

CONCLUSION

Intravitreal gas injection can be used to treat hypotony after cataract surgery in selected patients.

Treatment of bleb hypotony after phacoemulsification with autologous blood

Hypotony from an inadvertent filtration bleb developed in the eye of a 66-year-old woman 1 year after phacoemulsification cataract surgery. The hypotony was treated with an autologous blood injection over the previous phacoemulsification incision. This technique successfully treated the hypotony without additional ocular surgery. The authors report an effective alternative treatment for hypotony induced by an inadvertent filtration bleb.

Sulphur hexafluoride in the treatment of flat anterior chamber following trabeculectomy

The efficacy and side effects of sulphur hexafluoride (SF6) in the reformation of the flat anterior chamber (AC) after standard trabeculectomies were studied. Ten patients with lenticulocorneal touch following trabeculectomy were enrolled. All had water-tight conjunctival wounds with overflowing fistulas. In 5, one to four surgical attempts to reform the AC were unsuccessful. Two to seven days after trabeculectomy, the AC was reformed by a single injection of SF6/air mixture (20-40%). Gas was injected through the limbus at 3 or 9 o'clock. The AC remained deep after absorption of the gas in 2-7 days. All patients had stromal oedema in the first 4 days. This resolved and specular microscopy did not show any abnormality. After a mean follow-up of 2.5 years, all had normal intraocular pressure, 3 with one topical antiglaucoma treatment. Three patients developed cataracts before and 3 after reformation of the AC. The latter 3 were not anterior capsular cataracts as induced by gases. SF6/air mixture (20-40%) is inert and kind to the cornea and, as it is absorbed in less than 7 days, it exerts minimal damage to the crystalline lens. It is effective in the reformation of flat ACs.

[Postoperative flat anterior chamber. The therapeutic approach]

OBJECTIVE

The study of clinical entities followed by postoperative flat anterior chamber and their therapeutical possibilities. Retrospective study of all flat anterior chamber cases in a series of 315 patients operated for glaucoma. There were 16 flat anterior chamber cases with ocular hypotony, 3 cases with pupillary block and 9 cases with ciliary block. Stage I flat anterior chamber cases with ocular hypotony responded well to medical treatment. The most efficient surgical procedures were the application of additional sutures and excision of the over filtering bleb. The most frequent complications are: secondary cataract (75%), filtering failure (25%) and uveitis (18.75%). Flat anterior chamber cases with pupillary block resulted from obstruction and were managed with a new peripheral iridectomy. Flat anterior chamber cases with ciliary block had a severe evolution and didn't show any improvement under medical therapy. All cases were managed successfully by vitreous surgery (especially using pars plana aspiration). The incidence of postoperative flat anterior chamber can be reduced by accurate surgical procedure. Most of flat anterior chamber cases with ocular hypotony had a favorable evolution under medical treatment. Cases associated with intraocular hypertension needed surgical management.

Corneal blood staining following autologous blood injection for hypotony maculopathy

Hypotony is a common complication following trabeculectomy in which antimetabolites are used. Autologous blood injection is an accepted form of treatment for hypotony that occurs secondary to overfiltration; however, injection into the filtering bleb has been associated with a rise in intraocular pressure for some patients with chronic postoperative hypotony. The authors describe a patient in whom corneal blood staining with raised intraocular pressure and loss of vision occurred as a result of autologous blood injection.

Management of chronic hypotony following trabeculectomy with mitomycin C

Chronic hypotony is marked by decreased vision and late-onset leaking bleb after filtration surgery using topical mitomycin C; to manage this condition we followed a three-step approach: first, intrableb autologous blood injection; second, surgical exploration and additional suturing of the scleral flap; third, excision of the cystic bleb and advancement of a fornical conjunctival flap. For the avascular flap cystic blebs of five patients. In three of the six eyes, there was no increase of intraocular pressure (IOP); two eyes showed massive hyphema and were mildly resistant to the injection of autologous blood, and in one, a leaking hole was seen in the bleb wall two days after the injection of blood. Two eyes of three in which blood injection had failed, and another, in which the bleb had spread over more than half the eyeball, and which was the patient's only sighted eye, underwent the second step of the procedure. The remaining leaking eye, in which blood injection had been complicated, and another, in which spontaneous leakage from a thin avascular bleb had occurred, were subjected to the third step. After each of the three approaches, IOP increased on average from 1.67 to 5.67 mmHg, from 2.33 to 11.33 mmHg, and from 1.5 to 7 mmHg, respectively; each approach successfully improved vision. Intrableb autologous blood injection is a simple procedure for the management of chronic overfiltration and a way of determining whether excessive filtration is occurring through the scleral flap, in which case additional suturing is required, or in another way. Depending on the status of the bleb, additional suturing or excision of the cystic bleb and advancement of the fornical conjunctival flap are useful modalities for the treatment of late-onset leaking filtration bleb.

Severe visual loss after autologous blood injection for mitomycin-C-associated hypotonous maculopathy

It has been shown that mitomycin-C increases the success rate of trabeculectomy; however, a rise in the incidence of postoperative complications has also been reported. Consequently, the use of antimetabolite is usually reserved for patients who are at high risk of surgical failure or for patients with advanced glaucoma in whom low intraocular pressure is desired. This report describes a patient who suffered severe visual loss which was a direct result of hypotonous maculopathy after trabeculectomy with mitomycin-C and various other complications from the subsequent interventions.

Cryotherapy in the treatment of cyclodialysis cleft induced hypotony

A 26-year-old man with juvenile glaucoma developed persisting hypotonic retinopathy after trabeculotomy ab externo. An unintended cyclodialysis cleft at the site of the trabeculotomy was suspected, but visualization of the chamber angle was impossible due to a shallow anterior chamber. Seven months after the trabeculotomy the patient was treated with transconjunctival cryotherapy at the presumed localization of a cyclodialysis cleft. Eight days later an episode of acute ocular hypertension occurred, otherwise the postoperative course was uneventful with reversal of the hypotony and complete normalization of the visual acuity. The diagnostic and therapeutic problems of a hypotonous cyclodialysis cleft combined with a shallow anterior chamber are discussed.

Fibrin sealant in the management of complicated hypotony after trabeculectomy

BACKGROUND AND OBJECTIVE

In the postoperative course of trabeculectomy, hypotony may cause choroidal detachment with shallowing of the anterior chamber. If conservative medical treatment fails, a surgical revision may become necessary. To achieve only a temporary seal of the scleral flap, a subconjunctival tamponade with fibrin glue was performed.

PATIENTS AND METHODS

Two patients with corneal decompensation as a result of cornea-lens contact complicating hypotony with massive choroidal detachment are described. Hypotony occurred after trabeculectomy in one case and after combined cataract and glaucoma surgery in another case, and was not correlated to a leaking bleb. Temporary tamponade of the scleral flap was achieved by subconjunctival injection of fibrin sealant.

RESULTS

After the fibrin sealant was applied, the choroidal detachment resolved and intraocular pressure increased to normal. During the follow-up period of 6 months, a functioning bleb developed.

CONCLUSION

Subconjunctival application of fibrin sealant is effective for temporary closure of the scleral flap after trabeculectomy in eyes with massive hypotony syndrome.

Airbag-associated injury producing cyclodialysis cleft and ocular hypotony

Airbags have gained widespread acceptance as devices that reduce the morbidity and mortality associated with motor vehicle accidents. Recent reports of airbag-associated ocular injury suggest that further refinement in airbag technology may be warranted. The authors describe a patient who had a cyclodialysis cleft and ocular hypotony following injury to the eye from an airbag.

Injection of autologous blood for bleb leaks in New Zealand white rabbits

PURPOSE

Bleb leaks after trabeculectomy with antimetabolites can be recalcitrant to therapy. Peribleb autologous blood injections are a moderately successful new treatment modality for such leaks. However, it is unclear what mechanism the injections work to achieve leak resolution.

METHODS

A randomized, prospective study in the rabbit model was undertaken to evaluate further the clinical and histologic effects of peribleb autologous blood injection after leak induction in mitomycin-C exposed blebs, compared to controls that received only peribleb balanced salt solution injections.

RESULTS

In the blood-treated eyes, all bleb leaks healed. Control eyes either demonstrated persistent bleb leaks with shallow anterior chambers or failed blebs that were Seidel negative. Histologic results were remarkable for increased peribleb cellularity and collagen deposition in the blood-treated eyes, compared to controls.

CONCLUSIONS

Peribleb autologous blood injections are associated with bleb leak resolution, increased peribleb cellularity, and collagen deposition in the rabbit model.

Postsurgical hypotony: relationship to fistulization, inflammation, chorioretinal lesions, and the vitreous

Hypotony is a natural occurrence, symptom, and complication of surgical treatment. With more sophisticated and aggressive techniques, postsurgical hypotony recently has been given increased attention as an obstacle to success of surgery for glaucoma and retinal detachment. Whereas two standard deviations below normal pressure (15.9-5.8 = 10.1 mm Hg) can be called hypotonous, most eyes, depending on scleral rigidity, lid pressure, eye rubbing, or corneal or retinal edema, will be symptomatic at < 5 mm Hg. Hypotony can be defined as the low pressure (whether acute, transient, chronic or permanent) which, in an individual eye, leads to functional changes (whether asymptomatic or symptomatic) and structural changes (whether reversible or irreversible). Depending on its duration and degree, postsurgical hypotony produces characteristic tissue changes that often are modified by, but separate from, the tissue changes caused by an underlying disease or its surgical treatment. This review summarizes the situations, variably associated with hypotony, that occur after such interventions as cataract extraction, filtering surgery, cyclodialysis, cyclodestruction, and vitreoretinal surgery, in addition to the reported pathomechanisms of hypotony and its proposed treatments.

Use of oversized bandage soft contact lenses in the management of early hypotony following filtration surgery

BACKGROUND AND OBJECTIVE

Initial overdrainage following filtration surgery can be frustrating to manage. The authors reviewed the records of 10 patients with early postoperative hypotony following filtration surgery who were treated with application of an oversized 17.0-mm bandage soft contact lens (BSCL).

PATIENTS AND METHODS

Nine eyes had undergone trabeculectomy with either mitomycin-C or 5-fluorouracil intraoperative application, and one eye had undergone tenonectomy 4 years following trabeculectomy. On postoperative day 1, seven eyes were hypotonous, and three other eyes became hypotonous following suture removal or lysis. An oversized 17.0-mm BSCL was placed immediately following the diagnosis of hypotony on all eyes except one, which had the BSCL applied after 24 hours of observation.

RESULTS

In 9 of 10 cases intraocular pressure rose 5 to 12 mm Hg following placement of the BSCL. During a 6- to 18-months follow-up, all successfully treated eyes had final intraocular pressures of 5 to 11 mm Hg, with extensive low to moderate height blebs.

CONCLUSION

Oversized BSCLs can be a useful tool in the management of early hypotony following filtration surgery.

Management of hypotonous cyclodialysis with pars plana vitrectomy, gas tamponade, and cryotherapy

BACKGROUND AND OBJECTIVE

Cyclodialysis after ocular trauma or surgery may lead to hypotony and visual loss. A new surgical approach for the treatment of cyclodialysis is reported.

PATIENTS AND METHODS

In three patients with long-standing cyclodialysis and hypotony, a pars plana vitrectomy with gas tamponade and transscleral cryotherapy to the region of the cleft was performed.

RESULTS

In all patients intraocular pressure increased to normal or near normal, choroidal detachment and retinal and disc edema resolved, and visual acuity increased.

CONCLUSION

A hypotonous cyclodialysis can be successfully treated with vitrectomy, gas tamponade, and cryotherapy. This approach may be superior to other techniques if there are also additional posterior segment problems, or if there is lens dislocation.

Treatment of hypotony maculopathy after trabeculectomy

BACKGROUND AND OBJECTIVE

To determine if resuturing of the scleral flap to increase IOP in the post-trabeculectomy eye is an effective treatment of hypotony maculopathy.

PATIENTS AND METHODS

The medical records of nine consecutive patients who developed visual acuity loss after trabeculectomy related to hypotony maculopathy were reviewed to determine factors that contribute to successful restoration of visual acuity. The average age of the patients was 50 years and average refractive error was -4.25 diopters (D). Mean Snellen visual acuity dropped from 20/25 to 20/200 after the onset of hypotony.

RESULTS

Six of nine eyes recovered visual acuity to within one line of initial level after treatment of the hypotony. Four of these six eyes underwent resuturing of the scleral flap to reverse the excess filtration within 6 months of the onset of hypotony maculopathy. Five of these six patients had final vision of 20/30 or better. The mean phakic preoperative refractive error in these six eyes was -2.25 D, compared with a mean refractive error of -8.50 D in the three eyes with persistent visual loss (P = 0.002). After reversal of the hypotony, the average peak intraocular pressure in the six eyes with visual recovery was 33 mm Hg, compared with an average peak IOP of 7 mm Hg in the three eyes with persistent visual loss. (P = 0.015)

CONCLUSION

Although reversal of the hypotony maculopathy in six eyes was associated with a few weeks of higher than normal IOP, the final IOP was acceptably low. Five of six filtering blebs remained functional with a mean follow-up of 3 years. The final average IOP in the six eyes that were successfully treated was 12.7 mm Hg. In this series of patients, visual acuity was restored to eyes with hypotony maculopathy by increasing the IOP to higher than normal levels.

Management of overfiltering and leaking blebs with autologous blood injection

We describe our experience with intrableb autologous blood injection to manage over-filtering and leaking blebs. Autologous blood was injected into 12 thin cystic filtration blebs of 12 eyes. Indications for blood injection included symptomatic hypotony in five eyes, hypotony associated with bleb leakage in five eyes, and bleb leakage without hypotony in two eyes. Seven eyes (58.3%) were classified as successes and five eyes (41.7%) were classified as failures. The mean (+/- SD) follow-up was 6.8 +/- 2.6 months. Among the eyes classified as successes, a significant increase was noted in intraocular pressure and visual acuity by a mean (+/- SD) of 5.1 +/- 2.9 mm Hg and 5.3 +/- 2.1 lines, respectively. Bleb leakage resolved in four of seven eyes. The most common complication was hyphema formation. Injection of autologous blood into a filtration bleb is an alternative procedure for management of excessive filtration or bleb leakage in selected patients.

Treatment of hypotonous maculopathy after trabeculectomy with mitomycin C

We treated 34 eyes of 32 patients who developed a hypotonous maculopathy after a trabeculectomy with mitomycin C with various treatment strategies. Placement of a Megasoft Bandage Contact Lens in 24 eyes did not result in a notable increase in intraocular pressure or visual acuity. Intrableb injection of autologous blood in 22 eyes resulted in a mean +/- standard deviation (S.D.) increase in intraocular pressure from 4.3 +/- 1.8 mm Hg before injection to 8.6 +/- 4.6 mm Hg after injection. Mean logMAR visual acuity improved from 0.71 +/- 0.40 to 0.32 +/- 0.25. After a surgical revision of 16 eyes, intraocular pressure increased from 4.1 +/- 1.9 mm Hg to 11.3 +/- 4.0 mm Hg, and logMAR visual acuity improved from 0.61 +/- 0.30 to 0.22 +/- 0.24. At the last follow-up examination (12.2 +/- 5.1 months after the trabeculectomy), 31 eyes (91.2%) had an intraocular pressure greater than 6 mm Hg. Hypotonous maculopathy after trabeculectomy with mitomycin C can be treated successfully by autologous blood injection and surgical revision of the filtration site.

Treatment of postfiltration bleb leak by bleb injection of autologous blood

We treated a persistent, brisk bleb-leak after trabeculectomy with mitomycin C by bleb injection of autologous blood. Following preparation with povidone iodine, approximately 0.5 cc of whole autologous blood was injected into the bleb at the slit lamp. The leak resolved after 36 hours, and after 9 months' follow up, continued to function well.

Histopathologic effects of mitomycin C after trabeculectomy in human glaucomatous eyes with persistent hypotony

We evaluated the histopathologic findings in seven patients who underwent surgical revision of the filtration site after trabeculectomy with mitomycin C because of persistent hypotonous maculopathy. Light microscopic examination of subconjunctival tissue and sclera demonstrated hypocellularity of fibroblasts and disruption of the normal architecture. Tissue fragments at the margin of the bleb wall demonstrated scarring and contained multiple fibroblasts. Additionally, we investigated the histopathologic changes in an eye obtained from a patient who died one week after a trabeculectomy with mitomycin C. Transmission electron microscopy showed myelin figures, increased melanolipofuscin granules, vacuolated cytoplasm, and disrupted mitochondria of the ciliary body epithelium underlying the site of mitomycin C application. On the basis of these findings, both overfiltration because of tissue disorganization of the filtering bleb and aqueous hyposecretion because of ciliary body toxicity might be involved in the causes of persistent hypotony after mitomycin C trabeculectomy.

Successful surgical treatment of hypotony maculopathy following trabeculectomy with topical mitomycin C

Hypotony maculopathy, a clinical syndrome consisting of choroidal folds, retinal folds, and optic disc edema, results from severe, chronically decreased intraocular pressure (IOP). Conventional therapy consists of procedures designed to normalize the IOP. We treated a patient who developed hypotony maculopathy following trabeculectomy with mitomycin C. Despite normalization of the IOP with bleb revision, neither the posterior segment architecture nor visual acuity improved. Vitrectomy with mechanical flattening of the posterior segment via intraoperative instillation of perfluorocarbon liquid was performed. The choroidal folds resolved and visual acuity improved from 20/200 to 20/20. In eyes with hypotony maculopathy in which the posterior segment anatomy and visual acuity do not improve after IOP normalization, vitrectomy with heavier-than-water liquids may improve vision.

Hypotonus cyclodialysis cleft following anterior chamber intraocular lens removal

Inadvertent cyclodialysis cleft formation is a rare complication of intraocular surgery. We report a patient in whom a hypotonus cyclodialysis cleft developed following the removal of an anterior chamber intraocular lens. The cleft closed and the hypotony resolved after 1 month of topical atropine therapy.

Treatment of chronic postfiltration hypotony by intrableb injection of autologous blood

OBJECTIVE

To treat chronic hypotony with decreased vision after filtration surgery.

DESIGN

After observation from 3 1/2 to 13 months with no spontaneous improvement, eyes were treated with the experimental therapy and followed up closely to determine the results.

PATIENTS

Four eyes with chronic hypotony, selected from a series of 125 eyes receiving trabeculectomy augmented by intraoperative mitomycin. All eyes had posterior chamber pseudophakia. All eyes had postoperative laser cutting of sutures holding the scleral flap of the trabeculectomy.

INTERVENTION

After administration of topical prophylactic 0.3% ciprofloxacin hydrochloride and topical anesthetic, the bleb was inflated with whole autologous blood through a 27-gauge needle passed subconjunctivally into the bleb.

MAIN OUTCOME MEASURES

Change in intraocular pressure, change in vision, change in choroidal detachment, any type of complication.

RESULTS

Average intraocular pressure increased from 5.5 to 8.2 mm Hg. Average vision improved from 20/148 to 20/33. In two eyes with choroidal detachment, the detachment absorbed in one eye and decreased in the other. No complications occurred.

CONCLUSION

Intrableb injection of autologous blood deserves further study as a possible treatment for hypotony following filtration.

Inadvertent cyclodialysis cleft

We report four patients with functionally significant inadvertent cyclodialysis cleft. In three, the cleft followed uneventful extracapsular cataract extraction with posterior chamber intraocular lens implantation; in the fourth, blunt trauma with hyphema. Ocular hypotony resolved in three patients with medical therapy; the fourth required argon laser photocoagulation. Causes, clinical findings, and treatment of inadvertent cyclodialysis cleft are reviewed.