A 33-year-old black female suffered blunt trauma to her right eye on July 18 and 20, 2000, and presented with a hyphema, which resolved with atropine 1% and prednisolone 1%. Her vision remained persistently blurred, however, and examination revealed large monocular choroidal detachments and a large cyclodialysis cleft. The patient was referred to me for evaluation and management. She reported repeated episodes of domestic abuse resulting in a broken jaw, broken nose, and head lacerations. Her past medical history was remarkable for depression, treated with Paxil (GlaxoSmithKline, Research Triangle, NC). There was no past ocular history.
Figure 1. The preoperative appearance of the right eye demonstrates that even very large clefts can be difficult to see without gonioscopy.
On my examination, the patient's UCVA was 20/400 OD and 20/20 OS with a pinhole visual acuity of 20/200 OD. Her IOP measured 11.5 mm Hg OD and 16 mm Hg OS. There was no afferent pupillary defect, and her light sensitivities were equal. The anterior segment of her right eye is seen in Figure 1. The nasal chamber was very deep. There were 2+ white blood cells. The lens showed a 2+ posterior subcapsular cataract and phacodonesis. The lens also appeared to be subluxed anteriorly into the pupil. Gonioscopy revealed a cyclodialysis cleft extending from approximately the 12- to the 4:30-o'clock position in the right eye (Figure 2). Peripheral anterior synechiae appeared to have closed the remainder of the angle. There was sufficient choroidal detachment to permit visualization of the inside of the sclera almost as far as the equator of the globe. Posteriorly, the choroidal detachment extended into the macula. No retinal detachment had occurred, but there was a small amount of disc edema. The left eye was normal.
Figure 2. This slit lamp photograph depicts the nasal cyclodialysis cleft. Note the mottled brown pigmentation of the sclera's inner surface.
My impression was that severe blunt trauma to the right eye had resulted in the lens dislocation and a cyclodialysis cleft, which caused a large choroidal detachment and hypotony maculopathy.
HOW WOULD YOU PROCEED?
1. What approach would you use to repair the cyclodialysis cleft?
2. Would you address the lens at this time?
3. What would your plan be for handling the expected rise in IOP after closing the cleft?
SURGICAL COURSE
I repaired the cyclodialysis cleft by first making a conjunctival peritomy over the area of the cleft. I created a large, rectangular, partial-thickness scleral flap (much in the same fashion as a trabeculectomy flap) over the entire extent of the cleft. Next, I used a sharply pointed blade to make an incision in the floor of the flap (in the approximate location of the scleral spur) in order to enter the superchoroidal space. After using the blade to extend this incision to the entire length of the cleft, I employed a 10–0 PROLENE Polypropolene Suture (ETHICON, Somerville, NJ) to reattach the detached ciliary body and iris to the floor of the scleral flap in the incision. The reattachment was done in several running sutures covering approximately two clock hours each, and I closed the scleral flap and conjunctival peritomy with a 10–0 nylon suture. No cryotherapy was applied. A vitreoretinal subspecialist performed a pars plana vitrectomy and lensectomy. After suturing a posterior chamber IOL, I placed a Baerveldt 350 mm2 tube shunt (Pharmacia Corporation, Peapack, NJ) and Tutoplast pericardial patch graft (IOP Inc., Costa Mesa, CA) in a conventional manner.
OUTCOME
On the first postoperative day, the patient had a UCVA of 20/40+2 OD. The IOP of this eye was 13 mm Hg. The anterior chamber showed the tube and lens to be well positioned (Figure 3), and gonioscopy revealed that the cleft was completely closed. The choroidal detachment had almost completely resolved. The patient's UCVA OD subsequently improved to 20/25. She has suffered two bouts of cystoid macular edema, however, that resolved with topical-steroid and nonsteroidal medication. These complications reduced her UCVA to 20/40. The patient's IOP has never risen above 16 mm Hg.
Figure 3. This postoperative photograph of the patient's right eye shows the shunt and Tutoplast patch graft. The IOL is centered. That the nasal conjunctiva appears almost hemorrhagic is an artifact of the photograph; the conjunctiva is pigmented.
DISCUSSION
This case was unusual and difficult owing to the extent of the cleft. Although the literature includes several techniques for cleft repair (some of which are more suited for smaller clefts and pseudophakic eyes), I deemed it more reasonable to repair the cleft from an external approach, and also elected to have the patient undergo lens removal and a vitrectomy. Technically, it would have been easier to close the cleft prior to the vitrectomy, lens insertion, and shunt placement in this case. I did not employ cryotherapy to assist in cleft closure.
I was concerned about the expected IOP spike after the cleft's closure, especially because the remainder of the angle appeared to be synechially closed by anterior pushing from the dislocated lens. Despite the very large cleft, the IOP was not very low. I placed the shunt as a prophylactic device to prevent an IOP spike. I also ligated the tube with a 6–0 Coated VICRYL Suture (ETHICON) and created venting slits ahead of the ligature to allow some aqueous flow. I was deeply satisfied by the restoration of vision to a very traumatized eye.
Jeffrey D. Henderer, MD, is a member of the Glaucoma staff and an assistant surgeon at the Wills Eye Hospital in Philadelphia, and he is Associate Professor of Ophthalmology at Thomas Jefferson University School of Medicine. He holds no financial interest in any product mentioned herein. Dr. Henderer may be reached at (215) 928-3272; henderer@willsglaucoma.org.
