Surgical outcomes of partial ciliary body direct suturing under the scleral flap for traumatic cyclodialysis cleft: A five-case series.

BACKGROUND: Cyclodialysis cleft is an uncommon finding due to blunt ocular trauma. A larger and more chronic cyclodialysis requires surgical repair. The aim of this study was to introduce a minimally invasive suturing technique for the lens-sparing repair of traumatic cyclodialysis cleft and evaluate outcomes. METHODS: This study was a retrospective case series. The medical and surgical records of five patients with traumatic cyclodialysis cleft who underwent this surgery were reviewed. The surgeon (Y.S.) dissected a fornix-based conjunctival flap and created a 90° circumferential and limbal-based scleral flap. Several small incisions parallel to the limbus were made within the scleral bed 1.5 and 3 mm posterior to the limbus. After suprachoroidal fluid drainage, tiny bumps in the ciliary body were exposed from the incisions and sewn directly onto the scleral bed with 10-0 nylon sutures. RESULTS: The mean age of the patients was 37.8 ± 1.3 years. The mean duration from injury to surgery was 14.8 ± 16.7 months. Mean best-corrected visual acuity (BCVA) was 0.56 ± 0.70 and intraocular pressure (IOP) was 5.2 ± 1.9 mmHg. In all patients, IOP normalized and BCVA then returned to baseline following this procedure. Mean postoperative BCVA was 1.17 ± 0.86 and IOP was 17.8 ± 1.3 mmHg. Mean IOP and BCVA recovery times were 82.0 ± 139.6 and 294.3 ± 284.3 days, respectively. CONCLUSIONS: Partial ciliary body direct suturing under the scleral flap is a less invasive surgical option without lensectomy and considered safe and effective as a primary surgical repair for traumatic cyclodialysis cleft.

Evaluating Ciliary Body Damage Induced by Blunt Low Speed Impact Using Finite Element Simulation.

PURPOSE: To evaluate the ciliary body mechanical load during low speed impact using finite element method to explain the mechanism of the cause of angle recession and cyclodialysis cleft. METHODS: Optical coherence tomography images were obtained to assess the patient's ciliary body angle recession. A finite element eye model was established based on Virginia Tech eye model with the consideration of dynamic impact of a projectile striking an eye. The mechanical properties of the ocular tissues were obtained from literatures. The stress and strain were evaluated. RESULTS: The stress distribution of the eye was calculated. The stress concentration at zonules was observed after 0.75 ms of the impact. The maximum stress at the cornea reached 3.8 MPa. The maximum stress at ciliary body was 57 KPa, which has high probability to cause ciliary body injury. The maximum stress at zonules was 0.98 MPa. The lateral expansion also reduces the forces transmitted along the sclera to the rear part of the eye. CONCLUSIONS: The eye under frontal impact will result in lateral expansion, which increase the stretch force of the lens, zonules and ciliary body. This mechanism can be seen as the protection for retina. The boundary of ciliary body is the most vulnerable position, where angle recession and cyclodialyses cleft will occur before retina damage occurrence. TRANSLATIONAL RELEVANCE: The finite element model explains the blunt low speed impact induced ciliary body related injuries, which enables us to assess the ocular injury for low energy impact and better diagnosis and treatment in clinics.

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.

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.

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.

Cilioretinal Artery Branch Avulsion Secondary to Surgical Embolectomy: Management and Outcome.

We report the trans-operative approach and short-term outcome of a patient who suffered a traumatic avulsion of the cilioretinal artery branch during the surgical management of a cilioretinal arterial branch occlusion (CRABO) with intraocular embolectomy. A patient with acute CRABO underwent a pars plana vitrectomy with in situ embolectomy. The blocked artery was incised using 25 gauge vertical scissors, and embolus manipulation was done using microsurgical forceps. During embolus extraction, the occluded cilioretinal artery and its branch were inadvertently avulsed and torn with subsequent intense bleeding. Laser and endodiathermy were used for acute hemostasis. The maneuvers created an unintended retinochoroidal anastomosis. Visual field improvement was noted 3 months after the surgery. In the event of a complicated surgical embolectomy with the avulsion of the artery, the formation of a retinochoroidal anastomosis and reperfusion of the occluded may occur along with the improvement of visual fields in some cases.

One-step management of post-traumatic triple dialysis using two rings.

PURPOSE: To report a case that presented with post blunt trauma cataract, zonular dialysis, cyclodialysis and iridodialysis and its successful single-sitting management. METHODS: After lens aspiration, a capsular tension ring and multipiece intraocular lens were placed in the bag to support the zonules, a single eyelet Cionni ring was fixed in the sulcus to provide endocyclotamponade, and iridodialysis repair was done using the 'stroke and dock technique'. RESULT: Successful centration of the intraocular lens, closure of the cleft and apposition of the iris root to its base were achieved at the end of the surgery. CONCLUSION: A single-sitting surgery correcting all the three dialysis can curtail the burden of repeated surgeries and their complications, providing early visual recovery and cost-effectivity.

Single-suture single-knot ab interno cyclopexy for extensive posttraumatic cyclodialysis: Modified sewing machine technique.

We describe a modified sewing machine technique that is ab interno and minimally invasive. The single-suture, single-knot endocyclopexy (internal suture fixation) is performed to correct cyclodialysis. This inside-out technique is an alternative to existing standard cleft repair procedures, such as external direct/indirect cyclopexy and endocyclotamponade (internal mechanical tamponade using extraneous agents). Results in 1 case indicate that the modified technique can be used as a primary procedure and in eyes in which previous cyclopexy failed.

Case report of secondary pigment dispersion glaucoma, recurrent uveitis and cystoid macular oedema following inadvertent implantation of an intraocular lens into the ciliary sulcus following cataract surgery.

BACKGROUND: This case highlights the important sequelae that can occur following the inadvertent implantation of a single-piece intraocular lens into the ciliary sulcus during cataract surgery; secondary pigment dispersion glaucoma, recurrent anterior uveitis and macular oedema. CASE PRESENTATION: A 67-year-old lady underwent routine left cataract surgery in a separate unit but subsequently attended our eye casualty with recurrent hypertensive anterior uveitis. She was found to have secondary pigment dispersion glaucoma as the intraocular lens had been inadvertently placed into the ciliary sulcus. She underwent a trabeculectomy to control the intraocular pressure and initially settled well but 12 months later developed persistent anterior segment inflammation and macular oedema. She subsequently had the intraocular lens removed and the macular oedema was treated successfully with intravitreal Bevacizumab. CONCLUSIONS: We provide a summary of the evidence and a discussion over the management options available in managing such a difficult case.

Detection of pars plana rupture by ultrasound biomicroscopy after cannula dislodgement during cataract wound hydration.

Ultrasound biomicroscopy (UBM) is a valuable diagnostic modality for imaging anterior ocular structures. Its utility has been well studied in anterior segment, lenticular, and pars plicata pathologies. However, imaging of the pars plana has been seldom described. We present the case of a 66-year-old woman referred for vitreous hemorrhage after expulsive cannula dislodgement into the posterior segment during wound hydration at the end of cataract surgery. B-scan ultrasonography initially detected a very anterior abnormality, but the resolution was insufficient for accurate diagnosis. Subsequent UBM clearly showed rupture of the pars plana and a mild cyclodialysis cleft. To our knowledge, this is the first report of a pars plana rupture detected by ultrasound, which expands the diagnostic capacities and indications for UBM.

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.

Surgical reconstruction of traumatic ciliary body dialysis: a case report.

BACKGROUND: A cyclodialysis cleft is a gap resulting from disruption of the longitudinal fibers constituting the ciliary body attachment to the scleral spur. The cyclodialysis cleft can be of traumatic or iatrogenic origin, and it may occur during intraocular surgery or as a result of a glaucoma operation. In this report we present a surgical technique to treat cyclodialysis: cyclopexy combined with phacoemulsification subluxation lens, transscleral suturing of Cionni ring, and intraocular lens implantation with iris cerclage suture. CASE PRESENTATION: A 44-year-old Polish woman experienced a traumatic cyclodialysis cleft in her left eye, complicated by persistent hypotony, maculopathy, lens subluxation, and pupillary sphincter injury. Her corrected distance visual acuity was 0.1 (Snellen chart) and intraocular pressure 3.0 mmHg. We performed direct cyclopexy, anterior vitrectomy, removal of the subluxated lens by phacoemulsification, followed by an insertion of a capsular tension ring with 1-point scleral suture fixation with implantation of intraocular lens in the capsular bag and suturing around the pupil. Anterior segment optical coherence tomography revealed closure of the cleft by reattachment of the ciliary body to the sclera spur. Her corrected distance visual acuity was 0.8 and intraocular pressure 18 mmHg. CONCLUSIONS: The choice of operating technique depends on the area of the ciliary body dialysis, the number of clefts and their location, the presence of other abnormalities of the ocular structures, and the surgical skills of the operator. Cyclopexy combined with phacoemulsification and transscleral suturing of Cionni ring and intraocular lens implantation with iris cerclage suture can be a good solution in cases of this type. The applied surgical technique proved to be effective.

Cyclodialysis: an update.

Cyclodialysis is the result of the separation of the longitudinal ciliary muscle fibers from the scleral spur, which creates an abnormal pathway for aqueous humor drainage that may lead to ocular hypotony. For many years cyclodialysis was considered a treatment option for glaucoma. However, today it usually occurs as a complication of blunt trauma or more rarely as a complication of anterior segment ocular surgery. Ocular hypotony can lead to cataract development, optic disk swelling, refractive changes, and several retinal complications, making accurate identification and timely intervention of the cleft mandatory. Traditionally gonioscopy was the only available technique to diagnose and localize the cleft. However, other tests such as optical coherence tomography, magnetic resonance imaging, transillumination, and specially ultrasound biomicroscopy are now available for the diagnosis of cyclodialysis. Multiple treatment options are also available for this condition. Although medical treatment can be effective to close small clefts, surgery is needed in most patients to restore ocular pressure.

Long-term outcomes of argon laser photocoagulation in small size cyclodialysis cleft.

BACKGROUND: To evaluate the long-term outcomes of Argon laser photocoagulation compared to surgical direct cyclopexy in small-size cyclodialysis cleft patients. METHODS: This is a retrospective study. Small-size cyclodialysis cleft patients who underwent Argon laser photocoagulation and surgical direct cyclopexy were reviewed. The mean follow-up period were 82.4 (range, 61 - 145) months and 99.9 (range, 62 - 184) months in both groups. The comparison of best corrected visual acuity (BCVA), intraocular pressure (IOP), postoperative peak IOP and time to normalization of IOP before and after the treatment. RESULTS: The causes of all included 15 cyclodialysis cleft cases were blunt trauma. seven patients underwent Argon laser photocoagulation and eight patients underwent surgical direct cyclopexy. The mean age of included patients was not significantly different (p = 0.38). Preoperatively, the mean logMAR BCVA (standard deviation, SD) was 0.7 (0.2) and 1.1 (0.9) and mean IOP was 4.4 (2.4) mmHg and 3.0 (1.5) mmHg in Argon laser group and surgical direct cyclopexy group (p = 0.24 and p = 0.18, respectively). The extension of cyclodialysis and duration of cyclodialysis cleft were not significantly different between the two groups (p = 0.08 and p = 0.24, respectively). The mean follow-up period were 82.4 (range, 61 - 145) months and 99.9 (range, 62 - 184) months in both groups (p = 0.41). Postoperatively, the mean logMAR BCVA was 0.0 (0.1) and 0.2 (0.3) and mean IOP was 14.5 (3.1) mmHg and 16.8 (2.5) mmHg (p = 0.15 and p = 0.16, respectively). Postoperative peak IOP and time to normalization of IOP were not different between the two groups (p = 0.75 and p = 0.91, respectively). DISCUSSION: It is necessary to use invasive treatment such as cryotherapy or surgical direct cyclopexy in cyclodialysis cleft with hypotonic maculopathy. In the present study, Argon laser photocoagulation showed good prognosis in a small-size cyclodialysis cleft below 1.5 clock-hours. Considering possible complications and cost of surgical direct cyclopexy, Argon laser can be more beneficial than surgical direct cyclopexy in small-size cyclodialysis cleft below 1.5 clock-hours. CONCLUSIONS: The clinical ourcome of Argon laser photocoagulation seems to be as good as surgical direct cyclopexy in small-size cyclodialysis cleft below 1.5 clock-hours.

Cyclodialysis cleft with late hypotony maculopathy after inadvertent cannula detachment during cataract surgery.

We present the case of a 69-year-old woman who presented with hypotony several years after an inadvertent cannula detachment presumably formed a cyclodialysis cleft during phacoemulsification cataract extraction and posterior chamber intraocular lens implantation in her right eye. To our knowledge, this is the first report of late hypotony maculopathy as a result of inadvertent cannula release.

Introduction of lens-angle reconstruction surgery in rabbit eyes.

PURPOSE: In this study, we examined the stability of the lens-angle supporter (LAS) for accommodation restoration by comparing intraocular lens (IOL) location, after-cataract and ciliary body damage after cataract surgery in rabbits. METHODS: Eight rabbits were divided into experimental and control groups of four rabbits each. Phacoemulsification and irrigation and aspiration were performed in all rabbits. This was followed by an LAS and IOL insertion in the four experimental rabbits. In the four control rabbits, only an IOL insertion was performed. Six months after the surgery, the location of the IOL, the conditions of the lens capsule and ciliary body were evaluated using a slitl-amp examination and Miyake-Apple view. RESULTS: For the experimental group, the ultrasound biomicroscope results showed normal LAS and IOL positioning in all four cases. According to the slitlamp examination and Miyake-Apple view, the IOL was positioned at the center, with less after-cataract and damage to the ciliary body. For the control group, ultrasound biomicroscope results indicated a higher IOL position than normal, as well as a single case of IOL decentering. According to the slit-lamp examination and Miyake-Apple view, the IOL was decentered with more severe after-cataract and ciliary body damage. CONCLUSIONS: The LAS has the potential to maintain a stable IOL position while producing less after-cataract when used in lens-angle reconstruction for correction of presbyopia. Moreover, LAS implantation incurs less damage to the ciliary body.