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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 271-273

Cyclodialysis cleft following sutureless intraocular lens fixation by Yamane's technique and its management


1 Shri Bhagwan Mahavir Vitreoretinal Services, Medical Research Foundation, Chennai, Tamil Nadu, India
2 Smt Jadhavbai Nathmal Singhvee Glaucoma Services, Medical research Foundation, Chennai, Tamil Nadu, India

Date of Submission28-Apr-2020
Date of Acceptance08-Sep-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Ekta Rishi
Shri Bhagwan Mahavir Vitreoretina Services, Medical Research Foundation, Sankara Nethralaya, No 18, College Road, Nungambakkam, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1128_20

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  Abstract 


Intrascleral haptic fixation of intraocular lens fixation by Yamane's technique is a popular technique of scleral fixation of intraocular lens (IOL). We herein describe two eyes of two patients with cyclodialysis cleft formation as a complication of Yamane's technique and its subsequent management.

Keywords: Cyclodialysis cleft, hypotony, scleral fixated intraocular lens, SFIOL, Yamane technique


How to cite this article:
Mishra S, Rishi E, George R. Cyclodialysis cleft following sutureless intraocular lens fixation by Yamane's technique and its management. Indian J Ophthalmol Case Rep 2021;1:271-3

How to cite this URL:
Mishra S, Rishi E, George R. Cyclodialysis cleft following sutureless intraocular lens fixation by Yamane's technique and its management. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Apr 20];1:271-3. Available from: https://www.ijoreports.in/text.asp?2021/1/2/271/312319



Over the years, Yamane's technique of intrascleral haptic fixation (ISHF) of IOL which uses a 30-G needle-guided externalization of haptics has gained popularity. It is a relatively simple technique with good stability of IOL. We describe two cases where there was post-operative hypotony and cyclodialysis (CD) cleft following Yamane's technique of intraocular lens fixation.


  Case Reports Top


Case 1

A 45-year-old lady presented with posterior dislocation of crystalline lens in the vitreous cavity in right eye following blunt trauma with a shuttle cock. Intraocular pressure (IOP) by applanation tonometry (AT) was 7 and 8 mm of Hg in the right and left eye respectively. She underwent uneventful lensectomy with vitrectomy and ISHF by Yamane's technique of a 3-piece acrylic IOL using 30-G needle and fluid air exchange. Post-operative day 1 IOP was 10 mm of Hg with normal posterior segment findings. Three weeks postoperatively, the IOP was 2 mm of Hg. The hypotony persisted at 6 weeks with an AT of 01 mm of Hg with 6/9 vision. Fundus examination revealed disc edema with choroidal folds in the posterior pole [Figure 1]c. Ultrasonic biomicroscopy (UBM) showed a small CD cleft at 5 'O' clock position. [Figure 1]a and [Figure 1]b. Gonioscopy showed a small defect only of indentation at the same location. She was started on oral and topical steroids and underwent double frequency YAG laser to the CD cleft. There was no improvement in the hypotony and patient underwent transscleral cryotherapy to the CD cleft after 4 weeks of observation. IOP on postoperative day 1 was 6 mm of Hg. She presented after 3 weeks with an IOP of 55 mm Hg in the right eye, which was subsequently controlled with anti-glaucoma medications.
Figure 1: (a and b) Ultrasound biomicroscopy photograph of Patient 1 showing the cyclodialysis cleft at the 5 ‘o’ clock hour (Yellow arrows). (c) Spectral domain optical coherence tomography (Heidelberg engineering, Germany) shows the choroidal folds (White arrows) with optic nerve head edema due to persistent hypotony

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Case 2

A 43-year-old gentleman presented with history of trauma to the right eye for which he underwent intracapsular cataract extraction and anterior vitrectomy elsewhere. Later he underwent 23G vitrectomy with endolaser and C3F8 (14%) for retained cortical matter in the vitreous. Postoperatively, on day 1, IOP of 8 mm Hg in the right eye and at 6 weeks postoperatively, the IOP of 32 mm of Hg was recorded. The IOP was controlled with 3 anti-glaucoma medications. Intraocular lens fixation was done for the right eye by Yamane's technique. Post-operatively, day 4, AT was 8 mm of Hg. Anti-glaucomatous medications were stopped and reviewed at one week, with IOP of 2 mm of Hg. Patient was reviewed after 2 weeks with a non-recordable IOP with persistent hypotony [Figure 2]a. Gonioscopy showed a CD cleft at 5 and 11 'o' clock hours [Figure 2]b. UBM was done and CD cleft was noted in the same clock hours [Figure 3]a and [Figure 3]b. for which trans-scleral cryotherapy (TSC) was performed. Postoperative IOP was 0 mm of Hg. A repeat UBM after 6 weeks showed a persistent CD cleft at 5 o clock for which TSC was repeated. IOP increased to 16 mm Hg on follow-up at 6 weeks with closed cleft.
Figure 2: (a) Optos pseudocolor ultrawidefield imaging showing the optic nerve head edema (White arrow) along with the tortuous retinal vessels, with choroidal folds (more prominent around the inferior arcade). (b) Gonioscopy in the immediate post-operative period shows the cyclodialysis cleft (Yellow arrow). (c) Three-piece intraocular lens insitu following Yamane's technique

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Figure 3: (a) Ultrasound biomicroscopy (UBM) photograph of Patient 2 showing the CD cleft. (b) Closure of the cyclodialysis cleft after transcleral cryotherapy confirmed by a repeat ultrasound biomicroscopy (UBM)

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  Discussion Top


Yamane technique is a sutureless technique of IOL fixation and avoids sutured IOL complications including suture exposure and suture breakage. McAllister et al. found that suture breakage and exposure with 10-0 polypropylene suture occurred at a rate of 6.1% and 11% respectively.[1]

In Yamane technique, two angled incisions parallel to the limbus are made with a 30 gauge needle, with subsequent externalization of the haptics with the needle. The ends are cauterized and flange of the haptics pushed back and fixed into the scleral tunnels.[2] Kelkar et al. concluded in their study that the Yamane's technique was superior to other intrascleral IOL fixation technique.[3] The transconjunctival approach and less surgical time in addition to its needle-assisted approach for haptic externalization which prevented haptic damage during externalization makes it a popular technique with relatively less complications.

A CD cleft is formed when there is a detachment of the longitudinal ciliary muscle fibers from the scleral spur. This in turn forms allows passage of aqueous humor into the suprachoroidal space and thereby hypotony and its complications.[4],[5] CD cleft can be a consequence of blunt trauma or surgery.[4],[6] Both the described cases had a history of blunt trauma and were on topical anti-glaucoma medications before the surgery. Both patients underwent a gonioscopy evaluation after trauma with no evidence of CD cleft. Yamane technique involves the intraocular entry of a 30 G needle through the sclera and can push the ciliary body at that time as the entry is at close proximity of 1 mm from the limbus. Blunt needle and hypotonous globe during needle perforation might further cause more iatrogenic trauma to ciliary body and thereby might facilitate CD cleft formation. Both our patients developed a small cleft in the axis of IOL fixation thereby suggesting the possible iatrogenic cause of CD cleft formation. An early and prompt diagnosis of this entity by clinical suspicion aided with secondary investigations like UBM, gonioscopy, anterior segment optical coherence tomography (AS-OCT) may help to confirm and localize the lesion.

The treatment can be non-surgical[7],[8] or surgical.[9] Prednisolone eye drops, atropine eye drops, laser photocoagulation, cyclocryotherapy and trans-scleral diathermy are some of the non-surgical management options available. Both the patients in our series responded to TSC around the cleft area and one patient even landed in a high IOP post-procedure. The repeat UBM showed a closed cleft in both patients and the disc edema and choroidal folds regressed. An insertion more posteriorly, preferably 1.5 to 3 mm from the limbus may prevent this problem.[10] Hypotony following this procedure may frequently be encountered after the use of larger than 30 gauge needle for entry. We recommend a posterior entry, the use of new set of needles, in association with a well-maintained intraocular pressure at the time of intraocular entry to avoid such a complication and to have a high degree of suspicion in early postoperative hypotony patients.


  Conclusion Top


To the best of our knowledge, this is the first report describing CD cleft as a complication of Yamane's technique and its successful management.

CD cleft is a potential complication in the axis of IOL fixation during needle entry for haptic externalization. Transcleral cryotherapy may help in occlusion of the cleft and restoration of function.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McAllister AS, Hirst LW. Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg, 2011;37:1263-9.  Back to cited text no. 1
    
2.
Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology 2017;124:1136-42.  Back to cited text no. 2
    
3.
Kelkar A, Kelkar J, Kothari A, Mehta H, Chitale S, Fogla R, et al. Comparison of two modified sutureless techniques of scleral fixation of intraocular lens. Ophthalmic Surg Lasers Imaging Retina 2018;49:e129-34.  Back to cited text no. 3
    
4.
González-Martín-Moro J, Contreras-Martín I, Muñoz-Negrete FJ, Gómez-Sanz F, Zarallo-Gallardo J. Cyclodialysis: An update. Int Ophthalmol 2017;37:441-57.  Back to cited text no. 4
    
5.
Ormerod LD, Baerveldt G, Sunalp MA, Riekhof FT. Management of the hypotonous cyclodialysis cleft. Ophthalmology 1991;98:1384-93.  Back to cited text no. 5
    
6.
Ioannidis AS, Barton K. Cyclodialysis cleft: Causes and repair. Curr Opin Ophthalmol 2010;21:150-4.  Back to cited text no. 6
    
7.
Aminlari A, Callahan CE. Medical, laser, and surgical management of inadvertent cyclodialysis cleft with hypotony. Arch Ophthalmol 2004;122:396-8.  Back to cited text no. 7
    
8.
Harbin Jr, TS. Treatment of cyclodialysis clefts with argon laser photocoagulation. Ophthalmology 1982;89:1082-3.  Back to cited text no. 8
    
9.
Küchle M, Naumann GO. Direct cyclopexy for traumatic cyclodialysis with persisting hypotony: Report in 29 consecutive patients. Ophthalmology 1995;102:322-33.  Back to cited text no. 9
    
10.
Kelkar AS, Fogla R, Kelkar J, Kothari AA, Mehta H, Amoaku W. Sutureless 27-gauge needle-assisted transconjunctival intrascleral intraocular lens fixation: Initial experience. Indian J Ophthalmol 2017;65:1450-4.  Back to cited text no. 10
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