Ophthalmic Surgery, Lasers and Imaging Retina

Case Report 

Encircling Scleral Buckling for Traumatic Severe Hypotony

Eleonora B. Lávaque, MD; Mariano Iros, MD; Juan Pablo Real, MD; Alberto Zambrano, MD

Abstract

The authors report the use of an encircling scleral buckling procedure for the management of severe hypotony secondary to traumatic annular ciliochoroidal detachment (CCD) with cyclodialysis cleft. Medical records of patients with severe ocular hypotony were retrospectively reviewed. Four patients with traumatic annular CCD with cyclodialysis cleft were identified. Diagnosis of CCD was documented by ultrasound biomicroscopy and presence of cyclodialysis cleft was confirmed by gonioscopy or ultrasound biomicroscopy. All patients underwent scleral buckling surgery with an encircling band for annular CCD with cyclodialysis cleft. Intraocular pressure (IOP) and visual acuity (VA) significantly improved postoperatively. Mean IOP changed from 2.5 mm Hg ± 0.5 mm Hg to 10.75 mm Hg ± 1.1 mm Hg (P = .0129) and mean best-corrected VA changed from +0.50 ± 0.16 logMAR to +0.15 ± 0.17 logMAR (P = .0123). IOP normalization was achieved despite persistence of CCD. These results support the use of scleral buckling with an encircling band as an effective approach for severe hypotony in patients with annular CCD regardless the cyclodialysis cleft extension.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:58–63.]

Abstract

The authors report the use of an encircling scleral buckling procedure for the management of severe hypotony secondary to traumatic annular ciliochoroidal detachment (CCD) with cyclodialysis cleft. Medical records of patients with severe ocular hypotony were retrospectively reviewed. Four patients with traumatic annular CCD with cyclodialysis cleft were identified. Diagnosis of CCD was documented by ultrasound biomicroscopy and presence of cyclodialysis cleft was confirmed by gonioscopy or ultrasound biomicroscopy. All patients underwent scleral buckling surgery with an encircling band for annular CCD with cyclodialysis cleft. Intraocular pressure (IOP) and visual acuity (VA) significantly improved postoperatively. Mean IOP changed from 2.5 mm Hg ± 0.5 mm Hg to 10.75 mm Hg ± 1.1 mm Hg (P = .0129) and mean best-corrected VA changed from +0.50 ± 0.16 logMAR to +0.15 ± 0.17 logMAR (P = .0123). IOP normalization was achieved despite persistence of CCD. These results support the use of scleral buckling with an encircling band as an effective approach for severe hypotony in patients with annular CCD regardless the cyclodialysis cleft extension.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:58–63.]

Introduction

Cyclodialysis clefts are rare and generally occur after trauma or as an intraocular surgical complication. They occur when ciliary muscle fibers disinsert from the scleral spur, creating a pathway of aqueous humor drainage into the suprachoroidal space that, when combined with a reduction of aqueous humor secretion, usually results in ocular hypotony.1–3 Consequences of persistent low intraocular pressure (IOP) include hypotonic maculopathy, eye shrinkage, diffuse choroidal detachment, and phtisis bulbis.4 Thus, when hypotony occurs, its management becomes essential to prevent morphological changes and irreversible visual loss.5

Medical treatment is the initial approach and can be effective to close small and unique clefts; however, surgery is needed in most patients.3,6–7 Vitrectomy, direct ciclopexy, and cryotherapy have already demonstrated efficacy for repair of cyclodialysis cleft with partial ciliochoroidal detachment (CCD). Only a few cases of complete ciliochoroidal detachment (CCD) associated with clefts surgically treated have been reported in the literature. Moreover, annular CCD has been associated with poor results prognosis regardless the type of surgery.8–10 Herein, we report a series of four patients with severe hypotony secondary to traumatic annular CCD with cyclodialysis cleft successfully treated with an encircling scleral buckling procedure.

Patients and Methods

In this study, we retrospectively reviewed medical records of patients with severe ocular hypotension secondary to traumatic annular CCD with cyclodialysis cleft. Patients with penetrating injuries, tractional bands, and uveitis were excluded from the analysis.

The diagnosis of complete CCD was confirmed by ultrasound biomicroscopy (UBM) and cleft diagnosis was done by gonioscopy or UBM. Cyclodialysis cleft extension was 360° in patient No. 1 and 5- to 10-o'clock, 9- to 3-o'clock, and 12- to 3-o'clock in patients No. 2, 3, and 4, respectively.

A total of four male patients were identified. In all patients, surgical procedure was indicated after failure to respond to medical treatment. Only one patient (patient No. 4) was also treated with vitrectomy and direct ciclopexy.

All four cases underwent an encircling scleral buckling procedure. Surgeries were performed by three different surgeons using the following explants: Mira 503, E240, and E40 sponges (Mira, Uxbridge, MA). Sutures in the four quadrants were done with nylon 5-0, 2 mm back from muscles' insertion and were adjusted to produce a high indentation.

No drainage, cryopexy, or gas bubble was added in this series. There were no reports of intraoperative or postoperative complications.

All statistical analysis was performed using Infostat package (2016 version; Infostat, Sacramento, CA). Quantitative data were summarized using means and standard deviation (SD). Changes in quantitative variables were analyzed with the paired Student's t-test. A P value of .05 or less was considered statistically significant. Patients' informed consents were not obtained due the retrospective nature of this study.

Case Reports

Patient 1

Patient No. 1 was a 69-year-old male with history of trauma in his left eye (OS) 6 years ago. Since then, hypotony was present. No improvement in IOP was observed after phacoemulsification and intraocular lens placement. LogMAR best-corrected visual acuity (BCVA) was +0.30 with sphere +5.00 OS. Traumatic anisometropia was suspected with a sphere +2.00 in the right eye (OD) and sphere +5,00 OS refraction. Ocular examination OS revealed pseudophakia. IOP was 2 mm Hg by Goldmann applanation. Ocular fundus angiography and ocular coherence tomography (OCT) showed findings compatible with hypotonic maculopathy (Figure 1). Gonioscopic examination showed a four-quadrant, or 360°, iris root disinsertion. UBM confirmed presence of the annular cicliochoroidal detachment OS (Figure 1).

Patient No. 1. Images a, c, e, and g are preoperative; images b, d, f, and h are postoperative. Color retinography: (a) hypotonic maculopathy with evident macular folds, (b) without them. (c, d) Fluorescein angiography; both pictures with hyperfluorescent lines in (c) because of hypotonic maculopathy and in (b) still visible in a lesser degree due to the residual atrophy left by the macular fold. (e, f) Spectral-domain optical coherence tomography; (e) with subtle folds, (f) without them. (g, h) Ultrabiomicroscopy: a representative images of ciliochoroidal detachment.

Figure 1.

Patient No. 1. Images a, c, e, and g are preoperative; images b, d, f, and h are postoperative. Color retinography: (a) hypotonic maculopathy with evident macular folds, (b) without them. (c, d) Fluorescein angiography; both pictures with hyperfluorescent lines in (c) because of hypotonic maculopathy and in (b) still visible in a lesser degree due to the residual atrophy left by the macular fold. (e, f) Spectral-domain optical coherence tomography; (e) with subtle folds, (f) without them. (g, h) Ultrabiomicroscopy: a representative images of ciliochoroidal detachment.

An encircling scleral buckling procedure was decided upon. An explant E40 was sutured 11 mm from limbus at the four quadrants. At 1-month follow-up, the IOP increased to 10 mm Hg. Progressive resolution of hypotonic maculopathy was evidenced (Figure 1). At 14-months postoperatively, logMAR BCVA OS was +0.10, and IOP increased to 10 mm Hg. UBM revealed persistence of partial ciliochoroidal detachment (Figure 1).

Patient 2

Patient No 2. was a 33-year-old male who suffered an ocular contusion trauma OD with a tennis ball 2 months before the visit. His logMAR BCVA OD was +0.50, and IOP was 2 mm Hg. Ocular examination revealed decrease in the anterior chamber depth and pupillary sphincter rupture. Gonioscopy evidenced a ciliary cleft from 5-o'clock to 10-o'clock. Fundus examination revealed choroidal ruptures outside the macula area, laser cicatricial chorioretinitis, and hypotonic maculopathy OD (Figure 2). Ultrabiomicroscopy examination confirmed the presence of annular CCD. The patient was treated with topical steroids for hypotony with poor response; thus, surgical intervention was necessary. An encircling scleral buckling surgery was performed with explant E40, sutured 11 mm from limbus at four quadrants (Figure 2).

(a, c) Preoperative images. (d, b) Postoperative. Color retinography. (a) Shows hypotonic maculopathy, disc swelling, and vascular tortuosity. (b) The absence of this, signs of hypotony. (c, d) Representative images of cyclodialysis cleft and ciliochoroidal detachment.

Figure 2.

(a, c) Preoperative images. (d, b) Postoperative. Color retinography. (a) Shows hypotonic maculopathy, disc swelling, and vascular tortuosity. (b) The absence of this, signs of hypotony. (c, d) Representative images of cyclodialysis cleft and ciliochoroidal detachment.

At 10-day follow-up, IOP increased to 16 mm Hg OD. The patient was followed up for 25 years; ocular examination of the right eye revealed logMAR BCVA +0.10 and IOP of 13 mm Hg. Postoperative ocular fundus showed resolution of hypotonic maculopathy. UBM revealed residual ciliochoroidal detachment.

Patient 3

Patient No. 3 was a 28-year-old male who suffered ocular trauma OD 10 days before the visit. He was treated with cycloplegic and steroid drops for 6 weeks with poor response. His logMAR BCVA was +0.50 OD and IOP 2 mm Hg. A diagnosis of hypotonic maculopathy was made by fundus and fluorescein angiography examinations. UBM showed an annular CCD with CC (Figure 3). Circular scleral buckling surgery was performed with 240 band sutured anteriorly at four quadrants. A week after surgery, visual acuity improved to logMAR BCVA +0.30 OD and IOP increased to 10 mm Hg. At 3-month follow-up, logMAR BCVA was 0.00 and IOP 12 mm Hg OD. Postoperative UBM revealed a residual ciliochoroidal detachment. Ocular fundus and OCT showed resolution of hypotonic maculopathy (Figure 3).

(a, b, e) Preoperative images. (b, d, f) Postoperative images. Color retinography: (a) Shows hypotonic maculopathy; (b) resolution of hypotonic maculopathy. (c, d) Presence and absence of hypotonic maculopathy; ultrabiomicroscopy image shows in (c) cyclodialysis cleft and ciliochoroidal detachment (CCD), and in (d) a CCD.

Figure 3.

(a, b, e) Preoperative images. (b, d, f) Postoperative images. Color retinography: (a) Shows hypotonic maculopathy; (b) resolution of hypotonic maculopathy. (c, d) Presence and absence of hypotonic maculopathy; ultrabiomicroscopy image shows in (c) cyclodialysis cleft and ciliochoroidal detachment (CCD), and in (d) a CCD.

Patient 4

Patient No. 4 was a 38-year-old male who complained of worsened vision following a contusion trauma OD suffered a month before initial examination. Medical treatment with cycloplegic drops was indicated. Initially, IOP increased to 7 mm Hg, but after 1 month of treatment, pressure declined to 2 mm Hg. At the initial visit, logMar BCVA was +0.70 and IOP 5 mm Hg OD, with Tyndall 2+ and asymmetric anterior chamber. Posttraumatic anisometropia was suspected: sphere −4.50 OS and −0.50 OD. Fundus examination showed hypotonic maculopathy (Figure 4). UBM informed annular CCD with cyclodialysis cleft from 11-o'clock to 3-o'clock. Vitrectomy and direct cyclopexy were performed. By 6 months after surgery, IOP fluctuated between 2 mm Hg and 5 mm Hg. Focal cyclopexy with annular CCD was diagnosed by UBM. Because of persistence of ocular hypotension and extensive ciliary detachment, reintervention was indicated. An encircling scleral buckling surgery was performed using explant type Mira 503, sutured 2 mm posterior the muscle insertion at four quadrants. During the 2.5 years of follow-up, IOP was between 8 mm Hg and 10 mm Hg OD, and logMAR BCVA improved to +0.4 OD. Fundus examination revealed reduction in the antero-posterior diameter of the anterior chamber, posterior subcapsular cataract 2+ (Figure 4). UBM showed focal cyclopexy, persistence of partial ciliochoroidal detachment, and absence of hypotonic maculopathy. At 30-month follow-up, IOP was between 8 mm Hg and 10 mm Hg OD.

(a, b) Preoperative images. (b, d) Postoperative images. Color retinography: (a) evidence of hypotonic maculopathy, (b) residual subtle macular folds. (c, d) Ultrabiomicroscopy: representative images of ciliochoroidal detachment.

Figure 4.

(a, b) Preoperative images. (b, d) Postoperative images. Color retinography: (a) evidence of hypotonic maculopathy, (b) residual subtle macular folds. (c, d) Ultrabiomicroscopy: representative images of ciliochoroidal detachment.

Results

Patient preoperative and postoperative data are shown in Table 1. In this series, four patients with annular CCD with CC underwent scleral buckling surgery to treat persistent hypotony that did not respond to medical treatment. Before surgery, the mean IOP was 2.5 mm Hg ± 0.5 mm Hg. After surgery, mean IOP significantly improved to 10.75 mm Hg ± 1.1 mm Hg (P = .0129). Mean preoperative BCVA was +0.50 ± 0.16 logMAR, with significant improvement to +0.15 ± 0.17 logMAR (P = .0123) (Figure 5).

Preoperative and Postoperative Clinical Characteristics in Patients With Cyclodialysis Cleft

Table 1:

Preoperative and Postoperative Clinical Characteristics in Patients With Cyclodialysis Cleft

Average change in best-corrected visual acuity (a) and intraocular pressure (b) of patients after surgery; *P value < .05.

Figure 5.

Average change in best-corrected visual acuity (a) and intraocular pressure (b) of patients after surgery; *P value < .05.

In one case (patient No. 4), a significant improvement was observed in IOP and visual acuity; however, this improvement was counteracted by a posterior subcapsular cataract 2+ development.

Ciliochoroidal detachment and cyclodialysis cleft persisted in all patients after surgery.

Discussion

Cyclodialysis clefts are usually associated with chronic ocular hypotony. The main goal of treatment is to close the cleft to restore IOP as not only the duration of hypotony, but also the extent of cyclodialysis leads to irreversible visual loss. Surgical management is indicated when medical treatment of hypotony fails. The scleral buckling procedure is a widely used technique for repair of retinal detachment as well as proliferative vitreoretinopathy, and it has also been used to treat localized clefts with good results. Portney et al. used a sectorial and anterior buckle to abute the ciliary body detachment from 6.30-o'clock to 11-o'clock position with previous cryotherapy in the area where the buckle was going to be placed.11 Mandava et al. utilized a sectorial, separate and anterior buckle to abute the cyclodialysis cleft at 8.30-o'clock and 9.30-o'clock, 2 mm away from the limbus. After cleft closure the scleral buckle was removed.2

In this study, we found that IOP and BCVA significantly improved after the scleral buckle surgery with encircling band. The technique was the same as the accepted method for the treatment of rhegmatogenous retinal detachment with peripheral breaks except for drainage placement or gas bubble injection. Furthermore, normalization of IOP and complete resolution of hypotonic maculopathy was observed in all patients. In a previous published study, Inukai et al. also showed successful management of hypotonic maculopathy and peripheral retinal breaks using a 360° scleral buckling.12 Interestingly, as reported in previous studies, our patients showed clinical improvement even though persistence of CCD and cyclodialysis cleft.13,14 It could be hypothesized that the encircling procedure stop posterior displacement of suprachoroidal fluid thus reducing uveoscleral outflow.

So far, these results indicate that scleral buckling surgery with an encircling band appears to be an effective approach to manage persistent ocular hypotony in patients with annular CCD and cyclodialysis cleft in order to prevent irreversible ocular sequelae. Further prospective and larger studies are needed to confirm these findings.

References

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Preoperative and Postoperative Clinical Characteristics in Patients With Cyclodialysis Cleft

PatientAgeEyeCCPreoperativeBuckling TypePostoperativeFollow-Up
BCVAIOPUBMBCVAIOPUBMYears
169OS12 to 12+0.302ACCDE40+0.1010CCD1.5
233OD5 to 10+0.502ACCDE40+0.1013CCD25
328OD9 to 3+0.502ACCD2400.0012ACCD1
438OD11 to 3+0.702ACCDMIRA 503+0.4010ACCD2.5
Authors

From the Retina Department, Hospital Oftalmológico Santa Lucía, Buenos Aires, Argentina (EBL); the Ocular Microsurgery Institute, Córdoba, Argentina (MI); Pharmaceutical Technology Research and Development Unit (UNITEFA), CONICET, Universidad Nacional de Córdoba, Argentina (JPR); and the Zambrano Foundation, Buenos Aires, Argentina (AZ).

The authors report no relevant financial disclosures.

Address correspondence to Eleonora B. Lávaque, MD, Zabala 2463, PB “A,” C1426DQS, CABA, Buenos Aires, Argentina; email: eblavaque@gmail.com.

Received: February 06, 2019
Accepted: July 29, 2019

10.3928/23258160-20191211-09

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