Endocyclotamponade with pars plana vitrectomy for management of post-traumatic tractional cyclodialysis cleft.

A female in her 20s presented with a diminution of vision in the right eye (RE) following an open globe injury (scleral penetration) and repair a year back. At the presentation, she had low intraocular pressure (IOP) of 7 mm Hg, posterior subcapsular cataract (PSC), retrolental vitreous bands incarcerated at the penetration site, disc oedema, tortuous vessels and choroidal folds. Inferotemporal and superonasal cyclodialysis clefts were detected on CASIA 2 optical coherence tomography (OCT). The diagnosis of RE repaired scleral penetration, PSC and cyclodialysis cleft with hypotony maculopathy was made. The case was managed by phacoemulsification with an intraocular lens in the bag and a capsular tension ring in the sulcus, as a tamponading agent to close the cleft. Intraoperatively on endoscopic visualisation, vitreous membrane was noticed encasing the ciliary processes causing a tractional cyclodialysis and hence single port 23G pars plana vitrectomy was performed to relieve the traction. Postsurgery, IOP was 14 mm Hg, and the repaired cleft was visualised on anterior segment OCT.

Case report: A rare case of cyclodialysis after cataract surgery managed exclusively with medical therapy.

We present the case of a 68-year-old female who presented with a substantial cyclodialysis after phacoemulsification identified by anterior segment optical coherence tomography and ultrasound biomicroscopy. Gonioscopy is challenging because of its shallow anterior chamber. Due to lack of response to topical steroids and refusal by the patient for surgical treatment, topical steroids were tapered, and cycloplegic was initiated. After two weeks, the cyclodialysis cleft was closed on optical coherence tomography persisting residual subchoroidal fluid, topical treatment was mantained. Despite of this, visual acuity and hypotony were restored. Finally at 2 months visit subchoroidal fluid was reabsorbed and patient was discharged. Clinics should consider the possibility of cyclodialysis in cases of unjustified hypotony during postoperative period. In addition, we recommend performing anterior segment imaging which includes ultrasound biomicroscopy and optical coherence tomography, when the evaluation of angular structures is unfeasible. Finally, we propose medical management for severe cyclodialysis as the first option considering anti-inflammatory drugs could perpetrate the separation between scleral spur and ciliary muscle.

Modified technique for reconstruction of large cyclodialysis cleft with capsular tension ring and continuous and cerclage sutures without scleral flaps.

To present a modified technique for the reconstruction of a large cyclodialysis cleft with capsular tension ring (CTR) and continuous and cerclage sutures without scleral flaps in 12 cases. The mean visual acuity was 0.75 ± 0.47 logarithm of the minimal angle of resolution (logMAR), and the average intraocular pressure (IOP) was 3.35 ± 0.41 mmHg before surgery. Ultrasound biomicroscopy (UBM) revealed a ciliary cleft of 4.3 ± 3.5 clock hours. We performed the modified technique for the reconstruction of a large cyclodialysis cleft. Postoperative visual acuity improved to 0.48 ± 0.26 logMAR, and the IOP improved to 15.88 ± 3.81 mmHg. Postoperative UBM showed that cyclodialysis disappeared in the whole circumference of 12 eyes. The postoperative complications included 42% (5 eyes) with a temporary elevation of IOP and 16% (2 eyes) with a posterior shift of the ciliary body. No other complications were detected during the follow-up. Based on the results, our modified technique might be useful for most cyclodialysis clefts.

Cyclodialysis Cleft and Hypotony Following Combined Phacoemulsification and Excisional Goniotomy with the Kahook Dual Blade.

A 69-year-old woman with bilateral primary open-angle glaucoma who underwent cataract extraction with intraocular lens implantation and excisional goniotomy with the Kahook Dual Blade (KDB; New World Medical, Rancho Cucamonga, CA, USA) in both eyes one year prior was referred for evaluation of significant visual acuity loss and pain in the left eye. On initial examination, intraocular pressure in the left eye was 3 mmHg and slit lamp examination revealed normal anterior chamber depth. Gonioscopy revealed a cyclodialysis cleft that was confirmed by anterior segment optical coherence tomography. Prominent chorioretinal folds suggestive of long-standing hypotony maculopathy were observed during fundoscopic examination. The cyclodialysis cleft, thought to be created inadvertently during the KDB goniotomy, resolved after three sessions of argon laser photocoagulation and the patient's symptoms and visual acuity partially improved.

Intrascleral sewing-machine technique: A Grooveless/flapless cyclopexy technique for large traumatic Cyclodialysis cleft repairs in pars plana vitrectomy.

PURPOSE: To describe a minimally invasive technique for the repair of large traumatic cyclodialysis clefts using intrascleral sewing machine suture and overhand friction knot techniques in pars plana vitrectomy. METHODS: This prospective, noncomparative, interventional case series included seven eyes of seven patients with a large traumatic cyclodialysis cleft. The sewing machine technique was modified by an intrascleral approach. The procedure was transconjunctival or subconjunctival performed without scleral flaps/grooves. An overhand friction knot was used to lead the cutting ends of the suture buried in the scleral tunnel. RESULTS: The closure of the cyclodialysis cleft was achieved in seven eyes. The mean follow-up duration was 49.1 ± 15.6 weeks (range, 30-70 weeks). The intraocular pressure increased from 7.3 ± 2.1 mm Hg (range, 5-11 mmHg) preoperatively to 13.6 ± 2.4 mm Hg (range, 10-17 mmHg) postoperatively ( P < 0.01). The best-corrected visual acuity improved from a mean of 2.76 ± 2.77 logarithm of the minimum angle of resolution preoperatively to 0.63 ± 0.82 logarithm of the minimum angle of resolution at the final follow-up ( P < 0.01). CONCLUSION: In conclusion, the present technique is safe and effective in the treatment of large traumatic cyclodialysis clefts with minimal surgical trauma and a decreased surgical duration.

Cyclodialysis Cleft After Secondary Intraocular Lens Placement With Yamane Technique.

PURPOSE: The purpose of this study was to report a rare case of cyclodialysis cleft after secondary intraocular lens (IOL) placement using the Yamane flanged intrascleral haptic fixation technique. METHODS: This study is an observational case report. RESULTS: A 74-year-old man with an ocular history of spontaneously dislocated IOL and subsequent anterior chamber IOL (ACIOL) placement presented with monocular diplopia secondary to ACIOL subluxation. The patient underwent explantation of the subluxed ACIOL and placement of a scleral-fixated IOL using the Yamane technique. The postoperative course was complicated by persistent hypotony, prompting ultrasound biomicroscopy, which revealed a cyclodialysis cleft adjacent to one of the externalized IOL haptics. The haptic was discovered in the involved supraciliary space while performing direct cyclopexy. The cyclodialysis cleft closed with return to physiologic intraocular pressure. CONCLUSIONS: Cyclodialysis cleft formation is a possible complication of scleral IOL fixation and should be suspected in cases of prolonged postoperative hypotony. Extended longitudinal tracking of the needle and haptic through the supraciliary space may be one mechanism for cyclodialysis cleft formation in the Yamane technique.

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.

XEN-related hypotonous maculopathy from iatrogenic cyclodialysis cleft treated with argon laser gonio-cyclopexy.

We present a previously undescribed case of a persistent hypotony maculopathy secondary to an iatrogenic cyclodialysis cleft created during XEN-45 gel stent insertion. We present this case as a further analysis of the Karimi et al case of cyclopexy by the corresponding surgeon. Following right XEN-45 implantation, our patient developed immediate and persistent postoperative hypotony for 4 weeks. Gonioscopy revealed a small cyclodialysis cleft at the 1-2 o'clock position. The cyclodialysis cleft was sealed with direct gonioscopic argon laser cyclopexy. Two months after laser treatment and total of 6 months post XEN-45 insertion, right eye visual acuity returned to 6/4 with intraocular pressure 11 mm Hg without any glaucoma medication. Here, we present details of the non-invasive safe and successful management of hypotony maculopathy secondary to the cleft using Argon laser gonio cyclopexy, with no requirement of return to theatre.

Management of cyclodialysis cleft with transscleral cryotherapy.

A cyclodialysis cleft is a rare disease that is produced as a result of a separation of the longitudinal fibers of the ciliary body muscle from the scleral spur. A stepwise approach is the best course of action to treat cyclodialysis, starting with medical therapy and continuing with more invasive surgical options. We report a case of ocular hypotony due a traumatic cyclodialysis successfully resolved with transscleral cryotherapy.

VITRECTOMY + TRANSSCLERAL DIODE LASER CYCLOPEXY TREATMENT FOR 360° TRAUMATIC CYCLODIALYSIS AND HYPOTONY MACULOPATHY: CASE REPORT.

BACKGROUND/PURPOSE: To report a surgical approach of combined vitrectomy, gas endotamponade, and transscleral diode laser cyclopexy treatment for hypotony maculopathy induced by traumatic cyclodialysis. METHODS: A case of a 37-year-old male patient with decreased vision in his right eye because of hypotony maculopathy and 360° traumatic cyclodialysis is reported. Patient was initially treated conservatively with topical steroid + cycloplegic eye drops and repeated periocular corticosteroid injections with no improvement in the intraocular pressure and the anatomical defect. The patient underwent 23 G pars plana vitrectomy with 20% SF 6 gas endotamponade and supine position. Transscleral 810-nm laser burns were applied at 1.5 mm from the scleral limbus around the cornea in two confluent rows avoiding the horizontal meridians. Parameters used were 700-1,000 mW of power with a 2-second exposure in a continuous wave mode, and postoperative supine positioning of the head was indicated. RESULTS: Preoperative intraocular pressure improved from 2 mmHg to 10 mmHg at one week after surgical treatment and achieved 16 mmHg at one month to remain stable during a 6 months follow-up period. Presenting visual acuity was 1.0 logMAR (20/200 Snellen) and improved to 0.3 logMAR (20/40 Snellen) at Month 1 and achieved 0.1 logMAR (20/20 Snellen) at the third month. Complete closure of the cyclodialysis cleft and peripheral anterior synechiae formation were also observed at 3 months after treatment, with complete reattachment of the ciliary body demonstrated by ultrasound biomicroscopy and significant improvement of the macular anatomy demonstrated by spectral-domain optical coherence tomography. CONCLUSION: The combination of pars plana vitrectomy, supine positioning with gas endotamponade, and transscleral laser cyclopexy can successfully improve the visual and anatomical outcomes in patients with hypotony maculopathy and 360° traumatic cyclodialysis.

Temporary ab interno suture cyclopexy for closing a cyclodialysis cleft during cataract surgery.

Cyclodialysis clefts are often associated with ocular hypotony and attendant maculopathy. However, these clefts create an alternative aqueous outflow pathway that can be useful to maintain intraocular pressure (IOP) at physiologic levels under some conditions. At normal levels of IOP, they might prevent glaucoma damage and avoid maculopathy of hypotony. Indeed, historically, cyclodialysis was a planned surgical method for managing glaucoma, and more recently, a minimally invasive glaucoma surgery device that created a small-stented cyclodialysis was in use until removed from the market for unrelated concerns. Cataract surgery in the presence of a cleft, however, might be complicated by extensive fluid misdirection through the cleft with resultant large suprachoroidal effusion. A technique of ab interno temporary suture cyclopexy was devised for a patient needing cataract surgery with an existing traumatic cyclodialysis cleft that was vital for long-term management of IOP. The suture was used to close the cleft transiently during surgery and was removed at the close of the procedure to reestablish patency and preserve the cleft.

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.

Ciliary body suturing using intraocular irrigation for traumatic cyclodialysis: two case reports.

BACKGROUND: We report two cases (two eyes) of traumatic cyclodialysis with prolonged decrease of intraocular pressure that were successfully treated with surgery by ciliary body suturing using intraocular irrigation. CASE PRESENTATION: This study involved a 17-year-old Japanese boy (patient 1) and a 31-year-old Japanese man (patient 2) in whom cyclodialysis was sustained in one eye after blunt-force ocular trauma from a thrown ball. Because the hypotony maculopathy in both patients did not resolve after conservative treatment, ciliary body suturing was performed. Briefly, a 25-gauge trocar intraocular irrigation needle for vitrectomy was inserted into the vitreous cavity of the injured eye. A lamellar scleral flap was then made, and an incision was created on the sclera while maintaining intraocular pressure. Next, the detached ciliary body was sutured to the sclera under direct vision. The intraocular fluid at the site of cyclodialysis was then rapidly drained from the scleral wound because of elevated intraocular pressure in the vitreous cavity, and the ciliary body was visually recognized through the scleral wound under direct vision, thus allowing a stable suture fixation of the ciliary body to the sclera. Postoperatively, the treated eye in both cases showed improvement of intraocular pressure and visual function. CONCLUSIONS: The surgical method described in this report was found to be effective for draining intraocular fluid at the site of cyclodialysis and for performing a stable suture fixation of the ciliary body to the sclera through the scleral wound under direct vision, and it should be considered advantageous for avoiding intraoperative bleeding and suturing in a blinded manner.