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Traumatic Cyclodialysis Cleft and Hypotony Management in Ophthalmology

Explore the case of a 17-year-old female with OD trauma, hyphema, and hemorrhagic choroidal detachment leading to cyclodialysis. Learn about diagnosis, treatment options, complications, and management strategies for hypotony. Stay informed on surgical techniques, laser interventions, and medical protocols in restoring proper intraocular pressure.

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Traumatic Cyclodialysis Cleft and Hypotony Management in Ophthalmology

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  1. GRAND ROUNDS Denise A. John VEI 1/19/2007

  2. Case • HPI: 17 y/o ♀ s/p trauma OD ~ 2 wks earlier awoke in the AM with severe pain &  vision OD. • ROS: Headache & nausea x 2 days • PMHX: Umbilical hernia

  3. Case • POHX: • Trauma OD • Hyphema • Commotio retinae • Hemorrhagic choroidal detachment • ø Surgery/lasers • FHX: (-) • SHX: ø Tobacco/ETOH • Allergies: NKDA • Meds: PF 1% qid OD; stopped atropine 1% a wk earlier

  4. Case 20/400  NI • VAsc 20/30 • Motility: Full OU 52 • IOPA 16 • Pupils: Moderately dilated & sluggish OD; ø RAPD

  5. Differential Diagnosis • Hyphema • Traumatic iritis • Traumatic glaucoma • Lens-induced • Ghost cell • Trabecular meshwork damage/Angle recession • Steroid response • Closed cyclodialysis cleft

  6. Case • External exam: Unremarkable OU • SLE: • OD: 2+ conjunctival injection; corneal MCE; AC deep & formed with rare cell; multiple iris sphincter tears; lens clear & centered; trace pigmented vitreous cells • OS: Unremarkable • DFE

  7. Summary • Recent history of blunt trauma OD with period of  IOP with the development of a hemorrhagic choroidal detachment, optic disc edema, retinal venous engorgement & macular striae now with  IOP. • What is your diagnosis?

  8. What would you like to do next?

  9. Case • Assessment: • Spontaneous closure of a cyclodialysis cleft with  IOP • Plan: • IOP  to 32 (alphagan/cosopt/diamox) in clinic • Sent home on glaucoma gtts/diamox/PF & atropine • F/u 3 days

  10. Cyclodialysis: Pathophysiology • Blunt trauma: • Axial compression & rapid compensatory equatorial expansion

  11. Cyclodialysis: Pathophysiology • Separation of the longitudinal ciliary muscle fibers from the scleral spur •  Uveal-scleral outflow

  12. Cyclodialysis • Uncommon • Etiology: • Accidental • Blunt ocular trauma • Ocular surgeries involving manipulation of the iris tissue • Intentional • Glaucoma management

  13. Surgical Cyclodialysis • Heine,1905: • Alternative to filtering surgery, esp. in aphakic glaucoma • Unpredictable results • Complications: Hemorrhage, stripping of Descemet’s, corneal damage, tearing of the iris/ciliary body, lens injury & vitreous loss & phthisis

  14. Cyclodialysis: Complications • Hypotony (IOP < 6) • Internal filtration,  aqueous production or both • Often stabilizes in a few weeks • Magnitude of hypotony ø proportional to size of cleft • Variable VA • Transudation of protein-rich fluid into the subretinal space in posterior pole • Statistical association between IOP < 4 & VA< 20/200

  15. Cyclodialysis: Complications • Shallow AC • Induced hyperopia • Cataract • Choroidal effusion • Retinal & choroidal folds • Engorgement & stasis of retinal veins • CME • Optic disc edema

  16. Diagnosis • Clinical • Gonioscopy • Often small < 4 clock hrs • White band (sclera) below the TM • Ultrasound biomicroscopy (UBM) • Resolution  with higher frequencies at the expense of depth of penetration • 50MHz transducer • 50 μm resolution • 5mm penetration • Accurate assessment of location & size

  17. Cyclodialysis: Management • Goal: Reverse hypotony • Indications for treatment: • Hypotonous maculopathy + disc edema • Macular folds • Choroidal detachment • Corneal edema + worsening vision

  18. Cyclodialysis: Medical • 1st line treatment • Duration: 6 wks • Topical long-acting cycloplegic • 1% Atropine • Corticosteroids ø indicated

  19. Cyclodialysis: Laser • Argon laser photocoagulation (Joondeph,HC; 1980) • 400-800mW • 200μm spot size • 0.1-0.2 sec • Transscleral YAG laser cyclophotocoagulation (Brooks et al.; 1991) • 6 J power • 20 applications • 2-3mm behind limbus

  20. Cyclodialysis: Surgical Techniques • Ciliochoroidal diathermy • Direct cyclopexy • Indirect cyclopexy (McCannel retrievable suture) • Iris-base inclusion cyclopexy • Anterior scleral buckle • Vitrectomy/cryotherapy/gas tamponade

  21. Cyclodialysis: Hypotony Management • Aminlari et al , 2004, described the management of 7 pts with a cyclodialysis cleft • Etiology of cyclodialysis cleft • 1 eye: blunt trauma • 5 eyes: s/p ECCE • 1 eye: s/p trabeculotomy • Duration of ocular hypotony (IOP range 0-6mmHg) • 2 pts: 1-2 wks • 3 pts: 3-5 mos • 2 pts: > 1yr • VA pretreatment: Range 20/50-20/100

  22. Cyclodialysis: Hypotony Management • Management • 4/7 eyes: Medical tx (atropine 1% BID-TID) alone • Hypotony reversed within 1 wk • 2 eyes: 2 treatments of argon laser (1 wk apart) due to ø response atropine tid-qid • Hypotony reversed in 4 days • 1 eye: Surgical closure (direct cyclopexy) • Pediatric pt unable to cooperate at slitlamp for laser • Hypotony reversed POD#1 • VA post-treatment: Range 20/20-20/60

  23. Cyclodialysis: Management Algorithm Ormerod et al, 1991

  24. Cyclodialysis: Management • Cyclodialysis cleft may close spontaneously due to… • Inflammatory response • hyphema • Cycloplegia • May occur within first 6 wks • More common in children

  25. Cyclodialysis: Management • Following resolution, a self-limited ocular hypertension is common within the first 2 wks • IOP rarely > 45mmHg • Miotics are contraindicated

  26. Cyclodialysis: Prognosis • Vision often improves after hypotony is corrected (IOP: 6-12mmHg) • Best results with early correction • Vision may improve rapidly or take months • Delay of treatment > 8 wks  the risk of losing 1-3 snellen lines of vision

  27. Back to our patient… • VA 20/60; IOP nrl on f/u appt. • Tapered pred forte; atropine continued; glaucoma gtts/diamox stopped • ~ 2 wks after IOP normalized, recurrence of  IOP (38); VA 20/50+2; glaucoma gtts resumed; PF/atropine stopped • ~ 2 wk f/u IOP normalized; VA 20/25-2; glaucoma gtts continued • Follow-up 3 mos

  28. Take home points… • Cyclodialysis cleft should be considered with  IOP in setting of blunt trauma. • Closed cyclodialysis cleft should be considered with  IOP and a history of blunt trauma (within 6 wks) and  IOPwith signs of hypotony maculopathy &/or choroidal detachment. • Hypotony is the major complication & is responsible for vision loss. • A hypotonous cyclodiaysis cleft without retinopathy does not require treatment. • Goal of treatment is to reverse the hypotony • Medical treatment is the primary form of management for the first 6 wks.

  29. References • Ormerod et al. Management of a hypotonous cyclodialysis cleft. Ophth 1991; 98 (9): 1384-93 • Tran et al. UBM in the diagnosis & management of cyclodialysis cleft. Asian J Ophth, Vol. 4 (3) 2002; 11-15 • Hansen et al. Visualized cyclodialysis: an additional option in glaucoma surgery. Acta Ophth. 1986; 64: 142-45 • Joondeph HC. Management of postoperative & post-traumatic cyclodialysis clefts with argon laser photocoagulation. Ophth Surg. 1980; 11: 186-88 • Brooks et al. Noninvasive closure of a persistent cyclodialysis cleft. Ophth.1996; 103: 1943-45 • Aminlari et al. Medical/surgical/laser management of cyclodialysis cleft. Arch Ophth. 2004; 122; 399-404 • Alward. Color Atlas of Gonioscopy. AAO. 2001 • BCSC. Glaucoma. AAO. 2004-5 • Yanoff. Traumatic Glaucomas. 2nd Ed. 2004 • Allingham et al. Shield’s testbook of glaucoma. Traumatic Glaucomas. 5th Ed. 2005

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