Download grand rounds - Vanderbilt University Medical Center

GRAND ROUNDS
Denise A. John
VEI
1/19/2007
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
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
Case
20/400  NI

VAsc
20/30

Motility: Full OU

52
IOPA
16

Pupils: Moderately dilated & sluggish OD; ø
RAPD
Differential Diagnosis



Hyphema
Traumatic iritis
Traumatic glaucoma





Lens-induced
Ghost cell
Trabecular meshwork damage/Angle recession
Steroid response
Closed cyclodialysis cleft
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
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?
What would you like to do
next?
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
Cyclodialysis:
Pathophysiology

Blunt trauma:
 Axial
compression &
rapid
compensatory
equatorial
expansion
Cyclodialysis:
Pathophysiology


Separation of the
longitudinal ciliary
muscle fibers from
the scleral spur
 Uveal-scleral
outflow
Cyclodialysis

Uncommon

Etiology:

Accidental
Blunt ocular trauma
 Ocular surgeries involving manipulation of the iris
tissue


Intentional

Glaucoma management
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
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
Cyclodialysis:
Complications








Shallow AC
Induced hyperopia
Cataract
Choroidal effusion
Retinal & choroidal folds
Engorgement & stasis of retinal veins
CME
Optic disc edema
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
Cyclodialysis:
Management

Goal: Reverse hypotony

Indications for treatment:




Hypotonous maculopathy + disc edema
Macular folds
Choroidal detachment
Corneal edema + worsening vision
Cyclodialysis:
Medical

1st line treatment

Duration: 6 wks
 Topical long-acting cycloplegic
 1%
Atropine
 Corticosteroids
ø indicated
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
Cyclodialysis: Surgical
Techniques

Ciliochoroidal diathermy

Direct cyclopexy

Indirect cyclopexy (McCannel retrievable suture)

Iris-base inclusion cyclopexy

Anterior scleral buckle

Vitrectomy/cryotherapy/gas tamponade
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
Cyclodialysis:
Hypotony Management

Management

4/7 eyes: Medical tx (atropine 1% BID-TID) alone


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)



Hypotony reversed within 1 wk
Pediatric pt unable to cooperate at slitlamp for laser
Hypotony reversed POD#1
VA post-treatment: Range 20/20-20/60
Cyclodialysis: Management
Algorithm
1. Medical tx
2. Laser
3. Repeat laser
Ormerod et al, 1991
Small cleft
(< 2 clock hrs)
1. Direct cyclopexy
2. Ciliochoroidal diathermy
3. Indirect cyclopexy
Medium cleft
(2-4 clock hrs)
Large cleft
(> 4 clock hrs)
1. Direct cyclopexy
2. Ciliochoroidal diathermy
1. Direct cyclopexy
2. Anterior scleral buckle
Cyclodialysis:
Management

Cyclodialysis cleft may close spontaneously due
to…



Inflammatory response
hyphema
Cycloplegia

May occur within first 6 wks

More common in children
Cyclodialysis:
Management

Following resolution, a self-limited ocular
hypertension is common within the first 2
wks

IOP rarely > 45mmHg

Miotics are contraindicated
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
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
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  IOP with 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.
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