Clinical study of modified reposition surgery in the treatment of traumatic cyclodialysis / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To evaluate the therapeutical effects of modified reposition surgery in the treatment of traumatic cyclodialysis, and to explore a better surgical method for traumatic cyclodialysis. <p>METHODS: Totally 33 cases diagnosed of traumatic cyclodialysis were brought into observation. After accurately dialysis location of ciliary body through ultrasonic biological microscope, all cases received modified ciliary body reposition surgery. The period of follow-up was three to six months after surgery. The observation items included ciliary body status, intraocular pressure, visual acuity and complications and so on.<p>RESULTS:Among them, 30 cases were completely reposition during 1wk after surgery, 3 cases were found partial cyclodialysis, and then after half a month the three cases above got desirable outcome. Twenty cases were observed high intraocular pressure after surgery, 17 cases of which had high intraocular pressure returned to normal in 3d, 1 case of which had high intraocular pressure returned to normal in 1wk. 2 cases of which had high intraocular pressure were out of control through medicine, finally received anti-glaucoma surgery in 1 case, and the other one case underwent ciliary body laser photocoagulation and the high intraocular pressure was effectively controlled. Postoperative visual acuity was improved to some extent. There was no anterior segment ischemia or corneal macro astigmatism in all cases. <p>CONCLUSION:The modified reposition surgery in treating traumatic cyclodialysis is a simple, safe, effective, less iatrogenic injuries and fewer complications. It is worthy of clinical application.

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.

Transscleral Cyclopexy Using Partial-Thickness Scleral Flap for Repairing Cyclodialysis Cleft: a Case Report

PURPOSE: To report a case of a cyclodialysis cleft that was successfully managed with gonioscopically guided transscleral cyclopexy using partial-thickness scleral flap. CASE SUMMARY: A 44-year-old man complaining of blurred vision in the left eye after blunt trauma was referred to our hospital. The intraocular pressure (IOP) was 4 mmHg and the visual acuity was counting finger. Gonioscopy examination revealed cyclodialysis cleft from 3 to 6 o'clock and fundus examination revealed macular folds. After the failure of conservative medical therapy and laser photocoagulation, gonioscopically guided transscleral cyclopexy using partial-thickness scleral flap was performed. Four months later, the IOP was 18 mmHg, the visual acuity was 0.8, and fundus examination showed the disappearance of the macular folds. CONCLUSIONS: Transscleral cyclopexy using partial-thickness scleral flap is a safe and effective method to treat hypotony maculopathy due to cyclodialysis and to minimize pupil distortion.

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.

Ciliochoroidal effusion with persistent hypotony after trabectome surgery.

The trabectome is a novel form of ab interno trabeculectomy that ablates and remove the trabecular meshwork and the inner wall of Schlemm’s canal and subsequently expose the natural drainage pathway (the collector channels) to aqueous humor. Complications associated with the trabectome are few and among them is transient hypotony. We report a case of a prolonged ciliochoroidal effusion with hypotony after ab interno trabeculectomy using the trabectome with cyclodialysis cleft detected by 80 MHz ultrasound biomicroscopy in a previously neither nonoperated nor traumatized eye. Transient hypotony has been reported after the trabectome surgery. Very few cases were associated with inadvertent intraoperative cyclodialysis, but there are no cases of prolonged hypotony with ciliochoroidal effusion with cyclodialysis. In our case, associated transient intraoperative and postoperative hypotony with a history of chronically high pressure along with the possible contribution of low‑grade postoperative inflammation may have precipitated the ciliochoroidal effusion with prolonged hypotony associated with cyclodialysis.

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.

Analysis on the treatment of complicated ocular trauma accompanied with cyclodialysis / 国际眼科杂志(Guoji Yanke Zazhi)

AlM:To explore the effective method for the treatment of complicated ocular trauma accompanied with cyclodialysis.METHODS: Sixty - eight cases of complexity ocular trauma with cyclodialysis in different degrees were undergone vitrectomy and ( or ) combined with ciliary body reduction.RESULTS:All patients were followed up for 10 ~36mo (mean 17. 0±5. 7mo). The postoperative visual acuity was better than that of preoperation (P<0. 05). Compared with preoperative, intraocular pressure was significantly increased ( P < 0. 05 ). Successful rate of ciliary body restoration was 91%. CONCLUSlON: For the complicated ocular trauma accompaniedwith cyclodialysis, vitrectomy and ( or ) ciliary body reduction is an effective treatment method.

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.

Peri-operative Examination for Traumatic Cyclodialysis with Ultrasonic Biomicroscopy / 中国康复理论与实践

@# Objective To explore the use of Ultrasonic Biomicroscopy(UBM)for peri-operative examination of traumatic cyclodialysis.MethodsUBM was used in 33 eyes of 33 cases who were diagnosed as traumatic cyclodialysis.The morphologic characters were observed peri-operatively.ResultsCiliary detachment of 360° was verified in the 33 eyes with cyclodialysis of more than 2 clock hours.1 month after cyclopexy,the space of ciliary detachment disappeared or diminished and all reattached 3 months after operation.ConclusionUBM is safe and effective for checking traumatic cyclodialysis.

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.

Treatment of Hypotony Retinopathy with Cyclodialysis Cleft by Intravitreal Gas Injection

PURPOSE: We report a case of post-traumatic hypotony retinopathy with cyclodialysis cleft treated by intravitreal gas injection. METHODS: A 38-year-old man presented with decreased visual acuity after blunt trauma to the left eye. Visual acuity of the left eye was 0.06 and intraocular pressure was 1 mmHg. No external wound was found. The anterior chamber showed a microscopic hyphema and, upon funduscopic examination, mild macular edema and striae were seen. The cyclodialysis was identified using gonioscopy. We treated the patient with intravitreal gas (perfluoropropane, C3F8) injection under topical anesthesia and tracked the outcome of this treatment. RESULTS: On the first postoperative day, intraocular pressure fell to the normal range. After 7 days the visual acuity improved to 1.0. During a follow-up period of 10 months, intraocular pressure and visual acuity remained in their normal range. CONCLUSIONS: Intravitreal gas injection offers a safe and effective method of treating hypotony retinopathy with cyclodialysis cleft.

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.

Treatment of Hypotony Maculopathy Caused by Traumatic Cyclodialysis with Vitrectomy, Gas Tamponade, and Cryotherapy

PURPOSE: To report a case of hypotony maculopathy caused by traumatic cyclodialysis and treated by vitrectomy combined with gas tamponade and cryotherapy. METHODS: A 35-year-old man with hypotony maculopathy caused by traumatic cyclodialysis was unsuccessfully treated with conservative medical therapy, laser photocoagulation, and direct cyclopexy. The intraocular pressure (IOP) was 2 mm Hg and the vision was counting finger with chorioretinal folds. Vitrectomy combined with gas tamponade and cryotherapy was performed without lens surgery 5 months after trauma. RESULTS: After vitrectomy, fundus photograph and optical coherence tomography revealed complete loss of preoperative chorioretinal folds. The visual acuity improved to 0.3 and IOP was maintained within a normal range during the 24 month follow-up. CONCLUSIONS: This case shows that vitrectomy combined with gas tamponade and cryotherapy is effective for the treatment of traumatic cyclodialysis with persistent hypotony, probably without lens surgery.

Clinical Manifestations of Cyclodialysis Cleft and Prognostic Factors Associated with Direct Cyclopexy

PURPOSE: To evaluate the clinical manifestations and the factors associated with prognosis of the traumatic cyclodialysis patients who underwent direct cyclopexy. METHODS: The authors retrospectively analyzed the data of 23 eyes of 22 patients who underwent consecutive direct cyclopexy for the hypotonous cyclodialysis between 1997 and 2002 at the authors' institution. Perioperative A-scan and ultrabiomicroscopy were performed to evalaute correlation between the parameters and postoperative visual prognosis. RESULTS: Postoperatively, the mean increase of intraocular pressure was 11.1mmHg and the mean improvement of visual acuity was four lines of Han's Korean visual acuity chart. As the preoperative hypotony period was shorter, postoperative visual prognosis was better (p<0.05). Anterior chamber depth (p<0.0001), axial length (p<0.01), spherical equivalent (p<0.05), and intraocular pressure (p<0.0001) were increased, whereas lens thickness (p<0.0001) was decreased postoperatively. Transient postoperative ocular hypertension was controlled by adequate medication, and the patients' intraocular pressure were controlled below 20 mmHg without medications at the average of 19 days after the cyclopexy. Post-operative visual acuity was not significantly correlated with pre-operative intraocular pressure, pre-operative visual acuity, age, or sex. Preoperative extent of cyclodialysis was not significantly correlated with visual prognosis, postoperative development of cataract, intraocular pressure, or the cause of trauma. CONCLUSIONS: Direct cyclopexy is one of a successful method for the treatment of the hypotonous cyclodialysis cleft, and the early diagnosis and treatment are thought to be necessary for the improvement of visual prognosis.

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.

Treatment for Persistent Hypotony due to Cyclodialysis

We assessed 14 eyes of 14 patients with persisting hypotony due to cyclodialysis by blunt trauma of after secondary intraocular lens implantation. All the 14 eyes showed persistent hypotony and no increment of intraocular pressure(IOP) nor the visual acuity during the follow up period of average 4.6 months before treatment, We treated these eyes with argon laser photocoagulation and/or direct cyclopexy. After treatment, the IOP changed from 3.7+/-1.5mmHg to 13.7+/-5.1mmHg, and posttreatment IOP was greater than 8mmHg in 12 eyes. All 14 eyes showed visual acuity under 0.3 before the treatment and after treatment, the visual acuity improved by 4.2+/-3.3 lines at the last follow up visit. The follow up period was 12.5 months on average. Before treatment, all the 12 eyes that had no medial opacity showed hypotony maculopathy, but after treatment only 4 eyes showed persisting hypotony maculopathy. A-scan axial length measurement was performed on 8 eyes before and after treatment, and the axial lengths were increased by 0.90+/-0.88mm after treatment in 7 eyes in which IOP were increased. The change in refractive errors before and after treatment was possible to be assessed in 9 eyes and among them, 7 eyes showed increment of IOP. Among those 7 eyes, 2 eyes had shallow chambers with anteriorly displaced lens before treatment and showed repositioning of lenses and hyperopic shift by +2.86 Dsph on average after treatment, but the remaining 4 eyes excluding one eye that received lensectomy at the time of surgery for taumatic cataract, showed myopic shift by -2.31 Dsph on average after treatment.

A Case of Cyclodialysis Cleft Treated with Argon Laser Photocoagulation

Cyclodialysis with hypotony is defined as a rare disorder that meridional ciliary muscle is disinserted from its attachment at the scleral spur due to trauma or intraocula surgery such as extracapsular cataract extraction with or without intraocular lens implantation, iridectomy, and etc. Its managements include conservative therapy with cycloplegics, and surgical treatment such as argon laser photocoagulation, cyclopexy, and diathermy. The authors diagnosed cyclodialysis cleft by observing clinical features and finding of the cleft in the anterior chamber angle with gonioscopy. The cyclodialysis cleft with hypotony has been treated with argon laser photocoagulation into the cleft area.

Hypotony with Cyclodialysis after Blunt Trauma to the Eye

The hypotony with cyclodialysis after blunt trauma to the eye rarely happens and the cyclodialysis is diagnosed by finding the cleft in the anterior chamber anglel It is treated with cycloplegics conservatively or with surgery. In this study, the authors reviewed the hyphema, the onset of hypotony, the size of cyclodialysis cleft and transient scleral buckling that is one of the surgery in 7 eyes of 7 patients . The hyphema was seen in all cases after blunt trauma to the eyes and the duration between the trauma and the onset of hypotony was average 7.2 days. The traumatic cyclodialyses clefts were half an clock hour in 3 patients and 1 to 4 clock hours in 4 patients . Six patients had an initial conservative treatment, 3 patients required surgical treatment, scleral buckling, for 3 weeks for the full recovery of intraocular pressure.

Surgical Repair of Traumatic Cyclodialysis with Persistent Hypotony

Cyclodialysis is characterized by a disruption of the circumferential attachment of the fibers of the meridional ciliary muscle to the scleral spur. Cyclodialysis can lead to a marked chronic hypotony. Prolonged periods of hypotony can result in corneal edema, Descemet`s folds, shallow anterior chamber, cataract formation, chorioretinal folds that can involve the macula, and optic disc edema. The authors experienced a case of traumatic cyclodialysis with a persistent hypotony. We have treated with refixation of the detached ciliary body, by direct cyclopexy. Postoperatively, hypotony was disappeared and visual improvement was achieved.