Persistent Hypotony and Annular Ciliochoroidal Detachment After Microhook Ab Interno Trabeculotomy.

PRéCIS:: Creation of a cyclodialysis cleft can be a mechanism of ciliochoroidal detachment (CCD) and associated persistent hypotony after microhook ab interno trabeculotomy (µLOT). AIMS: To report persistent hypotony after µLOT, a minimally invasive glaucoma surgery (MIGS). SUBJECTS AND METHODS: This observational case series included 4 consecutive cases (3 men, 1 woman; mean age, 48.8±15.1 y) of persistent hypotony that developed after µLOT between May 2015 and March 2018. The patients' data and surgical results were obtained from the medical charts. RESULTS: All patients had open-angle glaucoma (2 juvenile, 1 primary, and 1 pigmentary) and were myopic (axial lengths, >24 mm). Two patients had undergone previous refractive surgery. µLOT alone was performed in 2 cases and combined with cataract surgery in 2 cases. In all cases, hypotony below 5 mm Hg was recorded 1 day postoperatively and sustained. In all cases, ultrasound biomicroscopy showed an annular CCD; communication between the anterior chamber and suprachoroidal space was detected in 3 of 4 cases. The hypotony resolved in 3 of the 4 cases from 2 to 8 months postoperatively, that is, spontaneously in 2 cases (cases 1 and 4) and after sulfur hexafluoride gas injection into the anterior chamber in 1 case (case 2). CCD resolution accompanied remarkedly high intraocular pressure, which required filtration surgeries. The incidence of persistent hypotony was 0.7% (4/547 eyes). CONCLUSIONS: After MIGS, persistent hypotony because of CCD rarely occurs. Increased uveoscleral outflow because of LOT or creation of a cyclodialysis cleft by traction of the pectinate ligament can be a mechanism of CCD development. Young age and myopia can be risks for cyclodialysis cleft formation and hypotony maculopathy after MIGS.

[Value of Pressure Measurements: Methods and Sources of Errors]. / Aktueller Stellenwert der Druckmessung: Messverfahren und Fehlerquellen.

Tonometry is still an essential component of diagnostic testing in glaucoma. Functional and morphological investigations can provide very detailed information about the extent of glaucomatous damage. They are useful in the early detection of glaucoma damage; when damage is manifest, they are useful in estimating the rate of progression in follow-up studies. In contrast, tonometric procedures are much less perfect and sensitive and provide no information at all about the extent of glaucoma damage. However, they often provide the first evidence that glaucoma may be present at all and they are the decisive parameter in controlling surgical or medical treatment to reduce pressure, as the reduction in intraocular pressure (IOD) is still the most common approach in treating glaucoma - in spite of our awareness of numerous other risk factors for glaucoma. There is no reason to doubt that reducing IOD is an effective therapy in many forms of glaucoma, as this has been demonstrated in numerous large epidemiological studies. Tonometric procedures have become more precise in recent years. Goldmann applanation tonometry (GAT) and pneumatonometry are widely used. There are also some areas for which the rarer forms of tonometry can be recommended. Procedures for quasi-continuous pressure measurements and, in the future, these may replace the current approach of measuring IOD at discrete time points. There are a variety of snares in clinical practice, which may lead to misinterpretation and wrong therapeutic decisions, so that these must be repeatedly emphasised.

Reversible Hypotony and Choroidal Effusion Following the Use of Pergolide for Parkinson's Disease.

PURPOSE: To alert clinicians of the possibility of reversible drug-induced occult hypotony and choroidal effusion following the long-term use of pergolide. METHODS: Annotations were made while the case was observed. The clinical records of the patient were reviewed retrospectively. RESULTS: A 74-year-old Caucasian male with primary open-angle glaucoma presenting with reduced vision in both eyes and an inflamed right eye. Examination revealed bilateral hypotony, right anterior chamber inflammation, and right choroidal effusion. The right intraocular inflammation resolved completely after a short course of topical and oral antibiotics in addition to topical steroids. Nevertheless, the bilateral hypotony and right choroidal effusion persisted. Only the discontinuation of pergolide allowed the complete resolution of the patient's presenting symptoms and signs. CONCLUSIONS: Pergolide is known to cause pericardial and pleural effusion, and generalized oedema. However, its association with choroidal effusion and hypotony has never been reported.

Direct cyclopexy surgery for post-traumatic cyclodialysis with persistent hypotony: ultrasound biomicroscopic evaluation.

Cyclodialysis is a relatively rare condition usually caused by ocular injury; however, it can also be caused iatrogenically during intraocular surgery. Hypotony maculopathy is the most important complication and the primary reason for visual loss. Clinical diagnosis using gonioscopy may be difficult, and ultrasound biomicroscopy (UBM) can be an alternative. There are different kinds of treatments, and the optimal one remains controversial. Here we describe a case of traumatic cyclodialysis with persistent ocular hypotony treated by direct cyclopexy, as illustrated by UBM performed before and after surgery.

Echography in extreme postoperativne ocular hypotony: case report.

A case is presented of excessive optic disk edema upon evacuation of the silicon oil instilled after vitrectomy. Retinal detachment in the right myopic eye of a 45-year-old female patient was the indication for vitrectomy with instillation of silicon oil. Consecutive cataract formation, shallow anterior chamber and corneal edema with slight ocular hypertonus lasting for two months were the reasons to perform phacoemulsification with posterior chamber lens implantation and silicon oil evacuation. Shallow anterior chamber and corneal edema persisted, accompanied by excessive hypotony. Echography revealed a highly echogenic massive lesion protruding from the posterior pole into the vitreal space without initial double spike, casting a shadow upon distal structures. The retrobulbar part of the optic nerve was not visible. Echographic presentation of the massive lesion was not corresponding to choroidal detachment and the diagnosis of excessive papilledema was established. Another procedure with refilling of the eye with silicon oil to restore the hypotony was performed. Regression of the papilledema was gradual, intraocular pressure normalized, and control echography showed flat optic nerve head.

Gas tamponade and cyclocryotherapy of a chronic cyclodialysis cleft.

AIMS: To describe a minimally invasive technique to treat a chronic large cyclodialysis cleft that had failed to respond to medical therapy. METHODS: A 51-year-old man with a history of blunt trauma developed a unilateral chronic ocular hypotony. He was treated with topical atropine 1% for 3 months. 12 months later, the patient was referred to our glaucoma service for evaluation and treatment of persistent hypotony. Ultrasound biomicroscopy (UBM) displayed a cyclodialysis cleft extending from the 6 to 12 o'clock positions. B-scan echography revealed a peripheral choroidal effusion. A single bubble of 20% sulfur hexafluoride was injected into the vitreous cavity and transconjunctival cyclocryotherapy was performed. RESULTS: After gas absorption, intraocular pressure increased to 12 mm Hg and became steady during the follow-up. B-scan echography showed the disappearance of choroidal effusion, and UBM displayed a complete closure of the cyclodialysis cleft from the 6 to 8:30 o'clock positions and from the 9:30 to 12 o'clock positions. A small cleft extending from the 8:30 to the 9:30 positions remained after the treatment, but the distance between the scleral spur and the ciliary boby decreased, and the cleft was limited at the back due to the scar formation. CONCLUSION: Gas tamponade with cyclocryotherapy represents a minimally invasive technique that is worth considering for patients with cyclodialysis clefts associated with a shallow anterior chamber and that had failed to respond to medical therapy. This technique should be useful in cases of cyclodialysis clefts that are not amenable to treatment with more conservative efforts.

Ultrasound biomicroscopy after vitrectomy in eyes with normal intraocular pressure and in eyes with chronic hypotony.

PURPOSE: To analyze the ultrasound biomicroscopy (UBM) features of eyes with chronic hypotony after pars plana vitrectomy (PPV) and compare them with the UBM features of eyes with normal intraocular pressure (IOP) after PPV. METHODS: This comparative (nonrandomized) interventional study included 64 eyes of 64 patients who underwent PPV. Group 1 included 20 eyes with less complex vitreoretinal diseases (VRD) that presented with normal IOP after PPV. Group 2 included 44 eyes with severe proliferative vitreoretinopathy (PVR) managed with PPV and silicone oil tamponade that presented with complete retina reattachment and chronic ocular hypotony. UBM was performed to study the anterior segment, ciliary body (CB), and peripheral retina. The UBM findings of the two groups were compared. RESULTS: In Group 1, 19/20 eyes presented with no CB alterations detected by UBM. In Group 2, 43/44 eyes presented with CB alterations that included tractional CB detachment (n=16); exudative CB detachment (n=11); tractional CB detachment/CB atrophy (n=7); CB hypotrophy (n=5); tractional CB detachment/exudative CB detachment (n=3); and CB edema (n=1). There was a strong relationship between IOP and CB findings revealed by UBM. CONCLUSIONS: Eyes with hypotony following PPV have CB abnormalities that can be detected by UBM. These CB alterations were not found in eyes with normal IOP after PPV in this series.

Choroidal effusion and hypotony caused by severe anterior lens capsule contraction following cataract surgery.

PURPOSE: The case report describes a case of severe anterior capsular contraction associated with choroidal effusion. CASE REPORT: An 81 year old female with primary open angle glaucoma underwent routine phacoemulsification cataract surgery. Eight weeks following surgery the anterior capsule opening had reduced to 3 mm in size. Intraocular pressure was found to be 4 mmHg and B scan ultrasound revealed a large choroidal effusion. Anterior capsulotomy with Nd:YAG laser was performed. At review, two weeks later, the choroidal effusion had resolved and visual acuity had recovered. DISCUSSION: The Nd:YAG laser radial relaxing capsulotomies helped relieve the capsular contraction and associated traction on the ciliary body.

[Ultrasonic biomicroscopic findings after spontaneous resolution of a traumatic cyclodialysis]. / Hallazgos en biomicroscopia ultrasónica tras resolución espontánea de ciclodiálisis postraumática.

CASE REPORT: We present one patient that received a blunt trauma in his right eye that resulted in ocular hypotension and hypotony maculopathy. UBM demonstrated the presence of a cyclodialysis. Several months later the patient experienced spontaneous improvement. A new UBM documented the presence of an anterior synechia closing the cleft. DISCUSSION: Ciclodyalisis is an infrequent problem. There are several treatment options, including conservative treatment, laser cyclopexy or surgical cyclopexy. Sometimes an spontaneous closure of the cleft may occur.

Ultrasound biomicroscopy in chronic ocular hypotony: its impact on diagnosis and management.

PURPOSE: To determine the value of ultrasound biomicroscopy (UBM) in the assessment of ocular hypotony in cases where the underlying pathologic mechanism remains unclear after extensive clinical examination. METHODS: In a retrospective study, the records of 60 patients who had undergone UBM to elucidate the underlying structural abnormalities of chronic ocular hypotony (intraocular pressure of 0-8 mmHg) were evaluated. Most patients (47 of 60 eyes) had a history of intraocular surgery or of other ocular diseases (e.g., uveitis), and after careful clinical examination, the cause had remained unclear. All patients were observed up for a minimum of 12 months. RESULTS: The associated pathoanatomy of the hypotony was demonstrated by UBM in 95% of the cases. Ciliary body abnormalities were present in 80% of the eyes. Therapeutic intervention was associated with restoration of normal ocular pressure in 50% of the cases. Often more than one intervention was necessary. A long duration of hypotony did not impede reaching the therapeutic goal of normalizing intraocular pressure and preventing phthisis. CONCLUSIONS: Ultrasound biomicroscopy is a new tool for detecting the underlying structural abnormalities in ocular hypotony. In cases where clinical examination is not sufficient it can be of great help in deciding on a course of treatment.

Typical ultrasound biomicroscopic findings seen in ocular hypotony.

UNLABELLED: Detailed imaging of the ciliary body region by means of ultrasound biomicroscopy can provide information that is crucial for further treatment whereas clinical evaluation and 10-MHz standard B scan are less helpful. BACKGROUND: To evaluate the suitability of ultrasound biomicroscopy (UBM) for elucidating the causes of ocular hypotony. PATIENTS AND METHODS: A retrospective chart review was performed to determine the usefulness of UBM in the evaluation of ocular hypotony. UBM, B scan, and a detailed clinical examination had been performed. Sixty patient charts with prolonged ocular hypotony of different causes were reviewed from January 1994 to December 1998. The information obtained by the UBM was classified into three groups: 'diagnostic' (group 1), 'helpful' (group 2), 'not helpful' (group 3). RESULTS: Of the 60 eyes, 45 UBM examinations (75%) were in group 1, 9 eyes (15%) were assigned to group 2 and 6 eyes (10%) were in group 3. The duration of hypotony had no influence. CONCLUSION: In cases of ocular hypotony, the cause was related to ciliary body pathologies in 80%. Only UBM could distinguish tractional from dehiscence ciliary body detachment which required a different management approach. UBM with its high resolution imaging of the anterior segment - including the ciliary body - is highly suitable for diagnostic clarification.

Value of high-frequency ultrasound biomicroscopy in uveitis.

PURPOSE: To determine the use of high-frequency ultrasound biomicroscopy (UBM) in the assessment of inflammatory lesions of the iris, ciliary body, pars plana and peripheral vitreous, and in particular to determine the proportion of cases for which UBM contributed significant additional, hitherto inaccessible, information. METHODS: Charts of patients seen in the uveitis clinic at University Eye Hospital from November 1994 to September 1999 for whom a UBM investigation had been performed were analysed. UBM was performed in a standard manner, using a Humphrey UBM 840 system. The clinical relevance of the UBM findings was determined for the whole series and for the following six subgroups of patients arbitrarily established according to the type and location of pathology: hypotony, pseudophakic uveitis, iris and ciliary body pathology excluding hypotony, pars plana pathology, scleritis and Toxocara uveitis. Findings were classified as positive when they confirmed a suspected diagnosis of lesional process or when they gave essential information. Findings were classified as essential when they led to the diagnosis or when they modified therapeutic intervention. RESULTS: During the study period 111 eyes of 77 patients were included. UBM findings contributed essential information that allowed a diagnosis to be reached or that influenced treatment in 43% of cases. It yielded positive findings in 91% of cases, enabling assessment of morphological changes in the iris, ciliary body, and retroiridal and peripheral vitreous induced by intraocular inflammatory or pseudo-inflammatory disorders. Specific UBM signs, present in all patients, were identified in Toxocara uveitis. The groups of patients that benefited most from UBM examination were those with hypotony (83% essential findings) and opaque media (100% essential findings). CONCLUSION: For uveitis patients with an inflammatory process situated in the iris/ciliary body/pars plana/retroiridal vitreous areas, UBM was of great clinical value and improved the management in a significant manner.

Occult wound leak diagnosed by ultrasound biomicroscopy in patients with postoperative hypotony.

PURPOSE: To describe the ability of high-frequency ultrasound biomicroscopy (UBM) to diagnose occult wound leaks as a cause for hypotony after cataract surgery. METHODS: Six patients with persistent hypotony after cataract surgery were sent for UBM examination. Slitlamp examination and gonioscopy of the 6 eyes had not revealed a cause for the hypotony. RESULTS: Ultrasound biomicroscopy showed subtle wound separation with shallow conjunctival elevation at the site of the cataract wound in the 6 patients. Two eyes had surgical repair of the subconjunctival wound leak, and the other 4 were treated medically. In the 2 eyes with surgically repaired wounds, the hypotony cleared after wound closure. Of the 4 medically treated eyes, hypotony resolved in 2 and 1 had a recurrence of hypotony. The other 2 eyes had fluctuating intraocular pressure for an extended period. CONCLUSIONS: Hypotony after cataract surgery occurred in 6 eyes due to subtle wound leaks difficult to detect by clinical observation. Ultrasound biomicroscopy can be a helpful aid to clinical examination in detecting these leaks.

Ultrasound biomicroscopy of chronic hypotony after cataract extraction.

Ultrasound biomicroscopy was performed with a UBM 840 (Zeiss-Humphrey) equipped with a 50 MHz probe on a patient with chronic hypotony 1 year after cataract surgery by phacoemulsification with intraocular lens implantation in the capsular bag. This sonographic technique, which provides high-resolution imaging of the anterior segment, showed aqueous humor leakage through the former scleral tunnel incision. Ultrasound biomicroscopy helped detect this patient's postoperative complication and is a good tool for diagnostic procedures in patients with chronic hypotony.

[Intraocular hypotony: use of ultrasound biomicroscopy (UBM) for differential diagnosis and its schematic representation]. / Hypotonie intraoculaire: revue des mécanismes et utilité de l'UBM (ultrasonographie biomicroscopique) dans le diagnostic différentiel et la prise en charge systématique.

OBJECTIVES: To determine the use of high-frequency ultrasound biomicroscopy (UBM) in the assessment of hypotony and in particular to determine the proportion of cases for which UBM contributed significant additional hitherto unaccessible information. PATIENTS AND METHODS: Ultrasound biomicroscopy was performed in a standard manner, using a Humphrey UBM 840 system (Humphrey Instruments, Inc., San Leandro, CA). UBM findings were analysed and the clinical relevance of UBM information was determined for the whole collective. RESULTS: Twelve patients with hypotony were examined. UBM findings contributed essential information that allowed to reach a diagnosis or that determined the therapeutic attitude in 10 of the 12 hypotonic patients. In two cases the cause of hypotony was tractional ciliary body detachment, in 5 cases it was post-inflammatory atrophy of the ciliary body, in 3 cases it was post-traumatic irido and cyclodialysis, in one case it was supraciliary and suprachoroidal effusion and in the last case it was due to uveal effusion syndrome. Based on these findings we established a schematic approach for hypotony. CONCLUSIONS: This procedure enabled us to assess the morphological changes found in patients with hypotony. In a majority of cases UBM was useful either to orient therapeutic intervention or to establish a diagnosis. On the base of our findings a schematic approach for hypotony, using UBM, was established.