Novel technique for traumatic cyclodialysis repair with phacoemulsification and Cionni's ring implantation

A 17-years-old boy presented with cataract, 360° choroidal effusion and disc oedema secondary to chronic hypotony. Gonioscopy and AS-OCT revealed 2 clock hours of cyclodialysis in the superonasal quadrant. The case was successively managed with phacoemulsification with foldable IOL in the bag and Cionni's ring sutured in the superonasal quadrant. Post surgery, the BCVA improved from counting finger 1 meter to 20/40. IOP returned to normal and there was resolution of choroidal effusion and fundus signs. The case highlights the use of Cionni's ring in management of small cyclodialysis cleft by providing internal compression.

Novel Adjuvant Method to Assist Localisation of a Cyclodialysis Cleft

PURPOSE: To introduce a novel adjuvant technique to locate cyclodialysis cleft using a laser pointer in a gonioscopic view. CASE SUMMARY: A 36-year-old man complaining of blurred vision in his left eye after blunt trauma 2 weeks prior was referred to our hospital. Gonioscopy showed a cyclodialysis cleft from 3 to 4 o'clock and fundus revealed hypotonic maculopathy. After the failure of medical treatment, we tried various interventions such as injection of viscoelastic agent into the anterior chamber and intravitreal gas tamponade with transconjunctival cryotherapy. Since those were not successful, we decided to treat the patient with direct cyclopexy. For the preoperative localization of the cleft, we tried a new technique that uses a laser pointer. On gonioscopic examination, an assistant shot the laser toward the limbal area where the suspicious cleft was located. We were able to precisely locate the cyclodialysis cleft if the laser pointer light was seen through the cleft in the gonioscopic view. With the aid of a laser a pointer, the cleft was successfully closed. CONCLUSIONS: Localization with a laser pointer is simple, safe, rapid, and helpful for planning surgical repair of a cyclodialysis cleft without expensive equipment.

A Case of Cyclodialysis Cleft with Hypotony during Ahmed Valve Implantation Surgery

PURPOSE: To report a case of cyclodialysis cleft with hypotony during Ahmed valve implantation. CASE SUMMARY: A 47-year-old male was referred for uncontrolled intraocular pressure (IOP) in the right eye. The patient had a history of ocular trauma and traumatic hyphema. He underwent pars plana vitrectomy, phacoemulsification and intraocular lens implantation 1 month prior due to rhegmatogenous retinal detachment. At the end of the Ahmed valve implantation surgery, the eye was hypotonic despite a deep anterior chamber. The hypotony continued and choroidal effusion developed. Anterior segment optical coherence tomography and gonioscopic examinations revealed small cyclodialysis clefts. After medical treatment with cycloplegics and steroids, choroidal effusion disappeared and IOP was normalized. CONCLUSIONS: Patients with previous ocular trauma or surgery could be prone to developing cyclodialysis cleft with hypotony. Inadvertent cyclodialysis cleft with hypotony can be treated with cycloplegics and steroids.

Cyclocryotherapy and Intravitreal Gas Tamponade of a Chronic Cyclodialysis Cleft: Case Report

PURPOSE: To report a case of chronic hypotony maculopathy caused by traumatic cyclodialysis cleft and treated with 20% sulfur hexafluoride (SF6) gas tamponade with cyclocryotherapy. CASE SUMMARY: A 39-year-old woman with a history of blunt trauma developed a unilateral chronic ocular hypotony in her left eye. She was treated with topical atropine sulphate 1% for 2 months. Three years later, she was referred to our clinic for evaluation and treatment of persistent hypotony. The intraocular pressure (IOP) was 4 mm Hg and the best corrected visual acuity was 0.4. B-scan echography revealed a choroidal effusion and fundus examination showed choroidal detachment and macular folds. Gonioscopy examination revealed cyclodialysis cleft from the direction of 7 o'clock to 11 o'clock. A single bubble of SF6 20% (0.4 cc) was injected into the vitreous cavity and transconjunctival cyclocryotherapy was performed under retrobulbar anesthesia. Six months later, the IOP was 12 mm Hg and the best corrected visual acuity was 1.0. B-scan echograpy and fundus examination showed the disappearance of the choroidal effusion. CONCLUSIONS: Gas tamponade with cyclocryotherapy may be useful in cases of cyclodialysis cleft that failed to respond to medical therapy.

Central Corneal Thickness and Visual Field Progression in Primary Open-Angle Glaucoma

PURPOSE: To find difference in the rate of visual field defect progression among primary open angle glaucoma (POAG) patients grouped according to central corneal thickness (CCT). METHODS: The medical records of 87 eyes of 87 POAG patients who received were on regular treatment and had a minimum of 5 years of longitudinal Humphrey automated visual field follow-up were reviewed retrospectively. The patients were divided into 4 quartile groups by CCT, and the correlations among clinical factors, such as intraocular pressure (IOP), and change in mean deviation (MD), were analyzed. RESULTS: The thinner cornea group showed a significant trend foward higher average, maximal, and yearly maximal IOP when the IOP was corrected by CCT (p<0.01), The rate of change in MD is significantly different; -0.33+/-0.6dB, -0.28+/-0.4dB, -0.09+/-0.2dB ,-0.02+/-0.2dB starting with the thinnest cornea group (p=0.036). Correlation analysis revealed a significant correlation between CCT and the rate of change in MD (r=0.351, p=0.001). CONCLUSIONS: In POAG patients who were on regular treatment at a tertiary referral hospital, patients with thinner cornea showed faster visual field defect progression.

A Case of Sudden Refractive Change with Intraocular Pressure Change Following Trauma

PURPOSE: To report a case of refractive change with intraocular pressure change following trauma. METHODS: Changes in intraocular pressure, refractive power, lens thickness, depth of anterior chamber, and axial length of an 8-year-old girl were measured. RESULTS: During the early period after trauma, the patient showed low intraocular pressure and shallow anterior chamber depth. The refractive power changed to transient high myopia. With temporary high intraocular pressure, the refractive power changed to hyperopia and the refractive power recovered toward emmetropia as the intraocular pressure fell to the normal level. Refractive alteration is a result of changes in intraocular pressure and depth of the anterior chamber by cyclodialysis cleft and its adhesion is induced by trauma to the eye. Herein, the authors show evidence for a relationship between refractive change and posttraumatic ocular change.

Clinical Features and Histopathological Findings of Traumatic Cyclodialysis Clefts

PURPOSE: Cyclodialysis clefts occur when the meridional ciliary muscle fibers become separated from the scleral spur, thereby providing a new drainage pathway of aqueous humor into the suprachoroidal space. Although the mechanism by which cyclodialysis lowers IOP is both of the hyposecretion of aqueous humor and the increased uveoscleral outflow, cyclodialysis clefts do not always cause hypotony. METHODS: The authors retrospectively analyzed the data of 9 eyes of 9 patients who had been diagnosed as traumatic cyclodialysis cleft by gonioscopic examination. RESULTS: Only 4 of the 9 eyes showed hypotony. This hypotony occurred 3 to 13 days (mean 7.3 days) after trauma. Conservative treatment combined with air injection was done in 4 patients with hypotony. In 3 eyes, IOP was normalized 7~10 days after the above treatment. The remaining one eye had an extensive cyclodialysis of 6 o clock and was treated with argon laser. But normalization of IOP was not achieved within the follow up period. Only cyclodialysis clefts of relatively small range were closed spontaneously or with only conservative management. Also posterior synechiae was found in one of the four eyes with hypotony, and was found in three of the four eyes without hypotony. CONCLUSION: Whether hypotony in cyclodialysis patients occur or not depends on the individual ability of scar formation in the cyclodialysis cleft against the anti-proliferative properties of aqueous humor.

A Case of Traumatic Cyclodialysis Cleft Diagnosed by Ultrasound Biomicroscopy

Cyclodiaysis is a disinsertion of the longitudinal muscle of ciliary body from its attachment to the sclera at the scleral spur, allowing direct communication between the anterior chamber and ciliochoroidal space. Although the diagnosis can usually be confirmed by gonioscopy, sometimes it may be difficult to detect the cleft in recently traumatized or operated eyes because of corneal edema, hyphema, or very shallow anterior chamber with hypotony. The authors experienced a case of traumatic cyclodialysis cleft which was difficult to detect due to shallow anterior chamber and hypotony. We diagnosed it easily using ultrasound biomicroscopy and treated it successfully by direct cyclopexy. Ultrasound biomicroscopy is a noninvasive method that can accurately diagnose the presence of traumatic cyclodialysis and can aid in surgical management. It is particularly useful in the presence of hazy media, hypotony, and/or abnormal anterior segment anatomy.