Main

Sir,

Cyclodialysis is a disinsertion of the ciliary body from the scleral spur. It may occur accidentally by trauma, iatrogenically during intraocular surgery, or deliberately as a planned procedure for the treatment of glaucoma. Cyclodialysis clefts may result in hypotony, shallow anterior chamber, hypotony maculopathy, and possibly loss of vision. Different treatment modalities have been reported to repair traumatic cyclodialysis.

We describe a patient with traumatic cyclodialysis that was treated successfully with pars plana vitrectomy, gas tamponade, and cyclopexy with trans-scleral diathermy following the unsuccessful use of trans-scleral ciliary body sutures. Ultrasound biomicroscopy (UBM) proved helpful to identify precisely the location and extent of the cyclodialysis cleft and to observe the regression of the ciliochoroidal space postoperatively with the closure of the clefts.

Case report

A 27-year-old man was referred to us for decreased vision with persistent hypotony in the right eye (RE) after colliding with motorboat while jet skiing 3 months earlier. The patient had undergone reconstructive surgery for maxillofacial fractures. On examination, best-corrected visual acuity was 20/200 RE and 20/10 left eye (LE) The intraocular pressure (IOP) was 2 mmHg RE and 14 mmHg LE. The anterior chamber was shallow, and a cyclodialysis cleft was found superotemporally. Ophthalmoscopy revealed swollen optic disc and oedema of the retina with macular folds. The LE was unremarkable. The axial length was 19.21 mm in the RE and 23.39 mm in the LE.

We performed a surgical cyclopexy by directly suturing the ciliary body to the scleral spur in the superotemporal quadrant, according to the technique reported by Küchle and Naumann.1 Following this treatment, no initial improvement was observed the IOP in the RE remained 2 mmHg. A posterior subcapsular cataract subsequently developed, and visual acuity decreased to 20/400. UBM (Humphrey UBM840, Humphrey Instruments, San Leandro, Ca, USA) examination of the ciliary body disclosed another cyclodialysis cleft nasally (Figure 1), that opened toward the anterior chamber and 360° of ciliochoroidal fluid.

Figure 1
figure 1

Nasal cyclodialysis cleft (arrow) is found behind closed angle and supraciliary fluid (asterisk). Imaging was limited because of patient discomfort.

Full size image

At 2 months after the initial operation, we performed phacoemulsification of the lens, intraocular lens implantation, three-port pars plana vitrectomy, peeling of the posterior hyaloid membrane and fluid–gas exchange with 20% SF6. At the end of the surgery, trans-scleral diathermy was applied posterior to the sites of the cyclodialysis clefts to anchor the ciliary body to the sclera firmly.

On the next day, the IOP showed a transient rise to 33 mmHg. The IOP decreased to normal range after the second postoperative day, and the ciliochoroidal detachment regressed. At 1 year after surgery, the best-corrected visual acuity improved to 20/20, and the IOP was 17 mmHg. UBM revealed closure of the nasal cyclodialysis cleft (Figure 2). The axial length of the right eye was elongated to 21.94 mm. Optic disc oedema and macular oedema had completely resolved.

Figure 2
figure 2

Closure of nasal cyclodialysis cleft is observed.

Full size image

Discussion

UBM provides high-resolution images of the anterior ocular segment and enables examinations focused on ciliary body abnormalities, especially in the diagnosis of post-traumatic and postoperative persistent hypotony. 2, 3, 4 Roters et al5 have reported that UBM revealed ciliary body abnormalities in 80% of eyes with chronic ocular hypotony in which the underlying pathologic mechanism remained unclear. UBM provides further information to clinical examination, as in the present case, in which an additional cyclodialysis cleft undetected during gonioscopy was disclosed by UBM after unsuccessful direct surgical cyclopexy.

Surgical treatment options for cyclodialysis cleft include laser photocoagulation,6, 7 cyclodiathermy,8 cyclocryopexy,9 and direct ciliary body suturing.1 Küchle and Naumann1 have reported successful surgical outcome with the direct suture technique in 29 consecutive cases. However, their approach has a disadvantage for larger or multiple clefts, because extended scleral lamellae have to be dissected, which could impair the blood supply by the anterior ciliary artery.10

It has been reported that long-standing traumatic hypotonous cyclodialysis had been successfully treated by pars plana vitrectomy with gas tamponade and cryotherapy.10, 11 In this technique, the intraocular gas bubble can be used as an internal tamponade for the detached ciliary body against the sclera.10, 11 Similarly in the present case, we performed pars plana vitrectomy, gas tamponade, and cyclopexy with trans-scleral diathermy as the second operation, to prevent further impairment of the anterior vascular supply. The pars plana approach is also optimal in managing coexisting intraocular problems, such as cataract, lens dislocation, and posterior segment conditions that are frequently present in traumatized eyes.

The application of UBM helps to identify precisely the location and extent of the cyclodialysis cleft,12 thereby providing a guide for surgical management in eyes with traumatic persistent hypotony.