Download Visualization and treatment of a Cyclodialysis Cleft Using Ocular

Visualization and Treatment of a
Cyclodialysis Cleft Using Ocular
Endoscope Technology
Annie Y. Chan M.D.
J. Matthew Rouse M.D.
Mahmoud A. Khaimi M.D.
Dean McGee Eye Institute
University of Oklahoma
The authors have no financial interest in the subject matter of this e-poster.
Purpose
• To report a novel method for definitive
diagnosis and primary closure of a chronic
cyclodialysis cleft using intraocular
endoscopy and diode endolaser
photocoagulation in a child who sustained
blunt ocular trauma.
Introduction
• A cyclodialysis cleft represents a separation of ciliary muscle
fibers from its insertion into the the scleral spur, ultimately leading
to hypotony from a direct communication between the anterior
chamber and suprachoroidal space.1 These clefts are most
commonly caused by blunt ocular trauma, but are also seen after
intraocular surgical manipulation.
• Definitive diagnosis with non-invasive techniques such as
gonioscopy and ultrasound biomicroscopy (UBM) requires
patient cooperation and can be difficult due to hypotony and
collapse of the anterior chamber and angle. Utilization of anterior
segment optical coherence tomography has been described in a
case study,2 but this method also needs adequate patient
cooperation.
• Methods of treating cyclodialysis clefts may also be limited by the
size of the cleft they can repair or may carry undesirable
complications such as surrounding tissue damage.
Case Presentation
• An 8 year old boy with a history of blunt trauma to the right eye
was initially evaluated and treated medically for a suspected
cyclodialysis cleft. He was referred for further evaluation
because of persistent visual reduction and hypotony despite this
treatment.
• Examination of his right eye revealed a best corrected visual
acuity of 20/125 with mild myopia. IOP was 3 mmHg and a
relative afferent pupillary defect of the right eye was noted.
• Anterior segment exam revealed a shallow anterior chamber and
early posterior capsular lenticular changes. Gonioscopy was
attempted, but no angle structures could be visualized due to
ocular hypotony. There were no significant anterior findings in
the left eye.
Case Presentation
• The decision was made to proceed with an examination
under anesthesia (EUA) including endoscopic evaluation
of the ocular angle structures. Consent was also
obtained from the patient’s parents for possible
endoscopic laser treatment to any area of cyclodialysis
cleft located on exam.
Posterior Segment OD
Fundoscopic exam
of the right eye
revealed macular
striae with
surrounding retinal
edema (orange
arrows) and marked
optic nerve head
edema (white
arrow).
Fundoscopic exam
of the left eye was
unremarkable.
Ultrasound Biomicroscopy OD
UBM was attempted during the EUA and did not definitively locate or
demonstrate the extent of the suspected cyclodialysis cleft. Findings
included shallow choroidals extending 360° (small arrows) and an
area suggestive of but not conclusive for a cyclodialysis cleft (large
Surgical Technique for EUA
and Treatment
• A paracentesis was then made at the limbus and the
anterior chamber was reformed with viscoelastic.
• Gonioscopy was repeated, which identified a potential
area for a cleft at the 7:30 position.
• A clear corneal incision was made at the 3 o’clock
position and the endoscope handpiece was placed into
the anterior chamber, allowing direct visualization of the
angle.
• The cyclodialysis cleft was clearly observed with the
endoscope and noted to extend approximately one clock
hour temporally.
• Angle recession was also observed 360°.
• Standard endoscopic photocoagulation was applied to
the area of the cyclodialysis cleft, resulting in shrinkage
of the iris at the iris root.
Results
• Three weeks after the
procedure, the patient’s IOP
increased to 40 mmHg,
signifying closure of the cleft
(figure left).
• Topical and oral IOP-lowering
agents were initiated.
• Five months postoperatively,
his IOP was 16mmHg while on
topical timolol 0.5% once daily.
His BCVA was 20/25 with mild
hyperopic correction.
Top: Deepening of the anterior chamber after endoscopic photocoagulation.
Bottom: Gonioscopy confirming closure of the cyclodialysis cleft.
Discussion
• This case demonstrates how intraocular
endoscopy can be used to definitively diagnose
and demonstrate the extent of a cyclodialysis
cleft through direct visualization.
• Endolaser photocoagulation can also be applied
at the same time to safely close the cyclodialysis
cleft with minimal discomfort or risk of damage to
surrounding structures.
• Endoscopy with endolaser photocoagulation
offers a promising method of diagnosing and
treating cyclodialysis clefts, particularly in the
pediatric population.
Diagnostic and Treatment Options for
Cyclodialysis Clefts3,4
Suspected
Cyclodialysis cleft
Indirect,
Non-invasive
visualization
• Gonioscopy
• UBM
Direct, invasive
visualization
Intraocular
Endoscopy
Medical
Management
• Mydriatics (e.g.
Atropine)
*
Non-incisional Treatment
• Gonioscopic laser
photocoagulation
• Transscleral diode or
YAG laser
• Cryotherapy
Incisional Treatment
• Cyclopexy
• Endolaser
photocoagulation
•Gas tamponade
Blue arrows: First-line management. *Consider incisional treatment for large clefts.
Red arrows: If medical treatment is unsuccessful or definitive diagnosis has not been
made, a direct diagnostic approach may be considered.
References
1. Ioannidis AS, Barton K. Cyclodialysis cleft: causes and repair.
Current Opinion in Ophthalmology. 2010;21(2): 150-54.
2. Mateo-Montoya A, Dreifuss S. Anterior Segment Optical
Coherence Tomography as a Diagnositic Tool for
Cyclodialysis Clefts. Arch Ophthalmol 2009; 127:109-110.
3. Aminlari A, Callahan CE. Medical, laser, and surgical
management of inadvertent cyclodialysis cleft with
hypotony. Arch Ophthalmol 2004; 122:399-404.
4. Omerod LD, Baerveldt G, Sunalp MA, Riekhof FT.
Management of the hypotonous cyclodialysis cleft.
Ophthalmology 1991; 98(9):1384-93.