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| CASE REPORT |
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| Year : 2022 | Volume
: 2
| Issue : 1 | Page : 112-115 |
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Bilateral cyclodialysis cleft following fire cracker injury managed by combined exocyclopexy and silicone oil endotamponade - An interesting case report
Vijayalakshmi A Senthilkumar1, Thandra S Shreya1, Naresh B Kannan2, Sharmila Rajendrababu1, Chitaranjan Mishra2, Dhipak Arthur2
1 Department of Glaucoma Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
2 Department of Retina and Vitreoretinal Surgery, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| Date of Submission | 10-May-2021 |
| Date of Acceptance | 09-Sep-2021 |
| Date of Web Publication | 07-Jan-2022 |
Correspondence Address:
Dr. Sharmila Rajendrababu
Glaucoma Consultant, Department of Glaucoma, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai - 625 020, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_1110_21
Cyclodialysis creates a direct communication between the anterior chamber and suprachoroidal space leading to ocular hypotony probably caused by an increased uveoscleral outflow and hyposecretion of the ciliary body. The sequelae of cyclodialysis include chronic ocular hypotony, anterior chamber shallowing, cataract, choroidal effusions, retinal and choroidal folds, hypotonus maculopathy, and ultimately loss of vision. Cyclodialysis clefts are a relatively rare condition usually caused by severe ocular trauma, and hence, the surgical repair techniques in the literature are limited. We present a case of post-traumatic bilateral cyclodialysis cleft with a successful outcome following combined exocyclopexy and silicone oil endotamponade.
Keywords: Bilateral cyclodialysis, direct cyclopexy, gonioscopy, silicone oil tamponade, surgical management, ultrasound biomicroscopy
How to cite this article:
Senthilkumar VA, Shreya TS, Kannan NB, Rajendrababu S, Mishra C, Arthur D. Bilateral cyclodialysis cleft following fire cracker injury managed by combined exocyclopexy and silicone oil endotamponade - An interesting case report. Indian J Ophthalmol Case Rep 2022;2:112-5 |
How to cite this URL:
Senthilkumar VA, Shreya TS, Kannan NB, Rajendrababu S, Mishra C, Arthur D. Bilateral cyclodialysis cleft following fire cracker injury managed by combined exocyclopexy and silicone oil endotamponade - An interesting case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:112-5. Available from: https://www.ijoreports.in/text.asp?2022/2/1/112/334854 |
Cyclodialysis is a vision-threatening ocular injury that often requires surgical correction.[1] Limited literature exists on surgical techniques as it is a rare entity.[2] We report an unusual case of bilateral multiple cyclodialysis clefts in a young male following a firecracker injury. Initially, ocular hypotony was managed conservatively with a tapering dose of topical steroids and cycloplegics. In view of the large extensive clefts involving more than 6 h, with persistent hypotony, we performed a combined cyclopexy with pars plana vitrectomy and silicone oil endotamponade in both eyes.
| Case Report | |  |
A 27-year-old male sustained bilateral ocular injuries following a firecracker accident 10 days before presentation. At presentation, his best-corrected visual acuity (BCVA) was finger counting close to face with an unrecordably low intraocular pressure (IOP) in both eyes (OU). A slit-lamp evaluation OU revealed Descemet's folds, 2 mm hyphema, aqueous flaring, Tyndall effect (+++) with mild phacodonesis and pigments on the anterior lens capsule, and traumatic mydriasis. B scan ultrasonography OU was unremarkable. He was treated conservatively as post-traumatic anterior uveitis with topical atropine and prednisolone acetate 1% eyedrops.
On review visit after a week, his BCVA improved to 20/60 in the right eye (OD) and 20/80 in the left eye (OS), with completely resolved hyphema, however, the IOP remained low at 4 mmHg OU. The fundus examination OU revealed optic disk edema with blurred margins, tortuous retinal vessels, macular folds radiating outward from the fovea, and 360° of shallow choroidal detachments [Figure 1]a and [Figure 1]b. The gonioscopic evaluation revealed multiple cyclodialysis clefts in 230° of the angles OD and multiple cyclodialysis clefts in more than 270° of the angles with blood in the Schlemm's canal and a few areas of angle recession in OS [Figure 2]a and [Figure 2]b. High-frequency ultrasound biomicroscopy (UBM) OU confirmed the gonioscopic findings which clearly showed the separation of the ciliary body from the scleral spur [Figure 2]c and [Figure 2]d. Owing to multiple large cyclodialysis clefts involving more than 270° of angles in OS with persistent hypotonic maculopathy, we performed a combined direct exocyclopexy with pars plana vitrectomy + silicone oil (SO) endotamponade to facilitate mechanical opposition of the detached ciliary muscle to the scleral spur. | Figure 1: (a and b) Fundus image of both eyes showing hypotony maculopathy (white arrowhead) with ILM folds over the macula
Click here to view |
 | Figure 2: (a and b) Gonioscopy image of both eyes showing the cyclodialysis cleft—irregular widening of the white ciliary body band (white arrowhead) with blood in the Schlemm's canal (white arrowhead). (c and d) High-frequency UBM image of both eyes showing cyclodialysis cleft with direct communication between the anterior chamber and suprachoroidal space (white arrowhead)
Click here to view |
A 23-gauge, three-port vitrectomy was performed. The posterior vitreous detachment was induced and the vitreous body was resected up to the periphery. Fluid gas exchange was done and 5000 cs SO was injected [Figure 3]a. The cleft area was identified gonioscopically and after conjunctival peritomy, surface marking was done on the sclera. A partial-thickness rectangular scleral flap was raised, 3 mm posterior to the limbus, and a deeper tissue was excised exposing the underlying choroid. Under direct visualization, the ciliary body was sutured to the scleral flap over the area marked using 9-0 nylon (Aurolon, Aurolab, India) horizontal mattress sutures [Figure 3]b. Finally, the conjunctiva and Tenon's were approximated using 8-0 vicryl (Polycryl, Aurolab, India) sutures [Figure 3]c. | Figure 3: (a–c) Intraoperative images showing steps of combined SO endotamponade and direct exocyclopexy (black arrowheads). (d) Postoperative (6 weeks) UBM image showing reattached ciliary body to the scleral spur (black arrowhead)
Click here to view |
At 2 weeks post-surgery, his BCVA OS improved to 20/40, with a well-formed anterior chamber and normal disks with a few choroidal folds at the macula and his IOP stabilized to 8 mmHg. Repeat UBM done postoperatively at 6 weeks confirmed the anatomical closure of the cleft in OS [Figure 3]d. As there were signs of improvement in the OS, we performed the same surgical procedure in the OD 2 weeks later. The patient showed a favorable outcome to surgery in both eyes with anatomical closure of the cleft, restoration of BCVA, and stabilization of the IOP at 6 months of follow-up.
| Discussion | | |
Cyclodialysis clefts are rare and the most common reason for presentation is blunt ocular trauma followed by various iatrogenic interventions.[1] Gonioscopy remains the gold standard for the identification of cyclodialysis clefts.[2],[3] However, a high-frequency UBM can be used to confirm the cyclodialysis cleft in cases where visualization and assessment of the drainage angle are complicated.[4] The cyclodialysis cleft results from the separation of the meridional ciliary muscle fibers from the scleral spur. The prevalence of cyclodialysis clefts following blunt injury is 2–5% or even higher.[5] The cyclodialysis clefts mostly recover spontaneously (especially if they involve less than 90° of the ciliary body) or with conservative management (1% atropine sulfate twice a day for 6–8 weeks).[6] Persistent cyclodialysis results in a shallow anterior chamber, ciliochoroidal detachment, ocular hypotony, and hypotony maculopathy with loss of vision.[7]
The successful outcome of cyclodialysis cleft repair is primarily dependent on the right localization and accurate estimation of the extent and number of clefts. Hence, preoperative and intraoperative gonioscopy and UBM, are mandatory.[2],[3] A detailed peripheral retinal evaluation with indentation to exclude any underlying peripheral retinal breaks or tears is mandatory, although contact procedures may be technically challenging in these hypotonus eyes. A few patients may experience severe pain during the scleral indentation techniques.
The main goal of the treatment is to close the cleft, restore the apposition of the ciliary body to the sclera and consequently increase the IOP, improve visual acuity, and prevent further complications, such as permanent vision loss.
Medical treatment with atropine drops and laser therapy to promote the reattachment of the ciliary body to the scleral spur is indicated in smaller clefts, but larger and more chronic cyclodialysis often require surgical repair.[6] Various treatment options have been proposed [Table 1].[6],[7],[8],[9],[10] Pars plana vitrectomy (PPV) with gas/oil tamponade has been proposed as an effective technique. Direct cyclopexy is the oldest and probably the most effective technique for closing a cyclodialysis cleft.[9] However, it may be fraught with complications such as hemorrhage, intraoperative hypotony, incomplete suture passes through the entire height of the cleft or the entire thickness of edematous detached Ciliary body (CB), cataract, retinal detachment, vitreous loss, wound dehiscence, and endophthalmitis.
After the repair of the cyclodialysis cleft and pars plana vitrectomy, either gas or SO can be used as a tamponading agent.[6] In the case of gas tamponade, the rate of postoperative gas resorption may not exactly synchronize with the reattachment of the ciliary body.[6] This makes SO the preferred tamponading agent. The SO is space occupying in the vitreous cavity, maintains ocular anatomy, prevents the inflammatory mediators from reaching the ciliary body which can adversely affect the aqueous production, approximates the detached ciliary body to the scleral spur, and thus, helps in its reattachment.[11]
The preference of 5000 cs SO over 1000 cs SO is due to the delayed emulsification, and hence, less risk of IOP rise in case of the former. The patient with a silicone oil-filled globe needs a close follow-up with respect to the raised IOP and consequent glaucomatous damage, which warrants SO removal. In the absence of glaucomatous damage, after the signs of hypotony are resolved, the reattachment of the cyclodialysis clefts is confirmed on gonioscopy and UBM, and the IOP is normalized. The SO can be removed to avoid glaucomatous damage.
| Conclusion | | |
In this interesting report, we highlight the unusual presentation of a bilateral multiple cyclodialysis cleft, discuss the need for a customized surgical regimen, and also demonstrate the postoperative anatomical closure of the cleft following a combined exocyclopexy, PPV, and endotamponade. Currently, we follow a conservative approach only as long as the patient's vision and hypotony are not worsening.
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.
Acknowledgments
Mr. Rajkumar, Photographer, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Gross JB, Davis GH, Bell NP, Feldman RM, Blieden LS. Surgical repair of large cyclodialysis clefts. Eur J Ophthalmol 2017;27:382-5.  |
| 2. | Wang C, Peng XY, You QS, Liu Y, Pang XQ, Zheng PF, et al. Internal cyclopexy for complicated traumatic cyclodialysis cleft. Acta Ophthalmol 2017;95:639-42. |
| 3. | Mushtaq B, Chiang MY, Kumar V, Ramanathan US, Shah P. Phacoemulsification, persistent hypotony and cyclodialysis clefts. J Cataract Refract Surg 2005;31:1428-32. |
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| 7. | Medeiros MD, Postorino M, Pallás C, Salinas C, Mateo C, Garcia-Arumí J, et al. Cyclodialysis induced persistent hypotony: Surgical management with vitrectomy and endotamponade. Retina 2013;33:1540-6. |
| 8. | Ioannidis AS, Bunce C, Barton K. The evaluation and surgical management of cyclodialysis clefts that have failed to respond to conservative management. Br J Ophthalmol 2014;98:544-9. |
| 9. | Wiechens B, Rochels R. Circular surgical cyclopexy after extensive traumatic cyclodialysis. Ophthalmic Surg Lasers 1996;27:479-83. |
| 10. | Ioannidis AS, Barton K. Cyclodialysis cleft: Causes and repair. Curr Opin Ophthalmol 2010;21:150-4. |
| 11. | Wang A, Zhao Z. Comparing vitrectomy, silicone oil endotamponade with/without cyclopexy to treat cyclodialysis clefts with severe ocular trauma. Retina 2021;41:1174-81. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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