A 75-year-old, white, Russian female complaining of decreased vision in her right eye presented for a second opinion. Her past ocular history was significant for open-angle glaucoma and cataracts, for which she had undergone combined cataract and glaucoma surgeries in both eyes. She reported having good vision bilaterally until approximately 5 years after surgery in her right eye, when she developed a painless decrease in vision. Her treating ophthalmologist had diagnosed the patient with a choroidal detachment due to hypotony and referred her to a retinal specialist, who resutured her trabeculectomy flap. In spite of this surgery, the patient's hypotony and choroidal detachment persisted. She then underwent reformation of her anterior chamber with a viscoelastic solution, which increased her IOP and improved her vision temporarily.
The patient's ocular medications on presentation included prednisolone acetate (Falcon Pharmaceuticals, Fort Worth, TX) b.i.d. and atropine q.d. in her right eye. She was taking timolol maleate (Falcon Pharmaceuticals) b.i.d. and latanoprost (Xalatan; Pfizer Inc., New York, NY) q.h.s. for her left eye. Her past medical history was significant for hypertension, non–insulin-dependent diabetes mellitus, atherosclerotic heart disease, and hypercholesterolemia. Her systemic medications included diltiazem, atenolol, glyburide, isosorbide, aspirin, and atorvastatin.
The initial examination in January 2001 revealed a BCVA of 20/200 OD and 20/40 OS. Her IOPs were 6 mm Hg OD and 24 mm Hg OS. Slit-lamp examination revealed corneal folds, a shallow anterior chamber, a PCIOL implant, and no discernable filtration bleb in the patient's right eye (Figure 1). Seidel testing of the superior conjunctiva overlying the scleral flap revealed no leakage, even with gentle pressure on the globe.
Figure 1. Examination of the superior perilimbal conjunctiva revealed a tightly sutured trabeculectomy flap with no discernable overlying filtration bleb. Seidel testing of this area was negative.
Optic nerve examination showed 0.3 C/D OD and 0.8 C/D OS. A low, inferior choroidal detachment was visible with indirect ophthalmoscopy in the patient's right eye. Gonioscopy of her right eye demonstrated a large, patent, internal sclerostomy superiorly, with a poor view of the angle structures through the corneal folds. Gonioscopy of her left eye revealed an open angle with a patent internal sclerostomy.
HOW WOULD YOU PROCEED?
1. What would be your differential diagnosis for the patient's hypotony?
2. What diagnostic tests or procedures would you perform?
3. What therapeutic approaches would you consider?
4. Incidentally, how would you manage her left eye?
SURGICAL COURSE
I instructed the patient to use her prednisolone acetate q.i.d. and prescribed a 7-day course of oral prednisone (60 mg q.d.). Her systemic beta-blocker was also discontinued after a consultation with her internist.
The patient returned 1 week later. She had a BCVA of 20/400 OD and 20/50 OS, and her IOP was 4 mm Hg OD and 28 mm Hg OS. She had ceased taking all medications except the prednisolone acetate, because she had noted no improvement in her condition. Her right eye's anterior chamber remained shallow, and larger nonkissing bullous choroidal detachments were now observable. At the slit lamp, I injected a viscoelastic solution into the anterior chamber through a temporal paracentesis. Immediately after anterior chamber reformation, the IOP was 26 mm Hg OD with no visible superior filtration bleb. Repeat gonioscopy revealed a probable cyclodialysis cleft posterior to the internal sclerostomy. I performed a needling bleb revision in her left eye a few days later.
In 3 weeks, the patient's visual acuity was 20/25 OD and 20/50 OS. Her IOP was 5 mm Hg OD and 11 mm Hg OS on no glaucoma medications. Both anterior chambers were deep and quiet. A diffuse superior filtration bleb was present in her left eye, whereas no filtration bleb was present in her right. Examination of the fundus showed resolution of the choroidal detachment in her right eye.
Five months thereafter, the patient's visual acuity had dropped to 20/40 OD, with an IOP of 5 mm Hg. I observed marked shallowing of the anterior chamber with peripheral iris-cornea touch as well as a recurrent choroidal detachment. Gonioscopic visualization of the superior angle was hampered by a large irido-corneal adhesion. After performing Nd:YAG laser lysis of this adhesion, I could clearly see a cyclodialysis cleft (Figure 2). The remainder of the right angle was closed. The cyclodialysis cleft was treated with argon laser during two separate sessions that occurred 5 months apart. One month after the second argon laser treatment, the patient's BCVA improved to 20/25 OD, with an IOP of 17 mm Hg. Her anterior chamber was deep, with focal peripheral anterior synechiae. No choroidal detachments could be appreciated.
Figure 2. Gonioscopy revealed a cyclodialysis cleft posterior to the internal sclerostomy. The peripheral lens capsule was visible through the iridectomy. The remainder of the anterior chamber angle was closed.
OUTCOME
The patient remained clinically stable for 2 years, until October 2003, when she presented to the emergency room with severe pain in her right eye and an IOP of 60 mm Hg OD. Emergent paracentesis was performed, and glaucoma medications were restarted. Gonioscopic examination revealed partial closure of the cleft by what appeared to be scar tissue or peripheral capsular fibrosis. Her medications were gradually tapered and discontinued. Upon her last examination in April 2004, her visual acuity was 20/25 OD, with an IOP of 6 mm Hg on atropine q.d.
DISCUSSION
An inadvertent cyclodialysis cleft following intraocular surgery is a rare complication, usually occurring after extracapsular cataract extraction but also reported after phacoemulsification through a scleral tunnel incision,1 anterior chamber IOL removal,2 transscleral fixation of a PCIOL,3 and holmium laser sclerostomy.4 There are also a few case reports of an inadvertent cyclodialysis following trabeculectomy.5,6 The case presented herein is unusual with respect to the complication's initial presentation years after surgery and its spontaneous closure years after argon laser treatment. As this case illustrates, the diagnosis of an inadvertent cyclodialysis cleft may not be straightforward but may require a high index of suspicion and careful gonioscopic examination. Anterior chamber reformation with viscoelastic and high-resolution ultrasonic biomicroscopy may be useful diagnostic adjuncts.7,8
The management of an inadvertent cyclodialysis cleft is directed toward limiting or eliminating aqueous outflow into the supraciliary space, normalizing IOP, and restoring vision. Less invasive treatments include cycloplegia and observation in cases where good visual acuity is retained.9 Cyclodialysis clefts unresponsive to conservative measures may respond to treatment with cryotherapy,6 argon laser,10,11 transscleral Nd:YAG laser,12 transscleral diode laser,13,14 or endoscopic laser.15 The definitive treatment of persistent or large cyclodialysis clefts involves cyclopexy, in which the ciliary body is reattached to the sclera with sutures.16 Surgical closure may also be accomplished with vitrectomy, cryotherapy, and intraocular gas tamponade.17,18 The closure of a cleft usually results in a hypertensive phase, which is transient in eyes with an underperfused yet functional trabecular meshwork. The patient described in this case demonstrates a completely closed angle apart from the area of cyclodialysis. If the cleft closes permanently in the future as a result of additional scarring, a trabeculectomy or other filtering procedure may well be required to maintain a safe and consistent IOP.
George Tanaka, MD, is Assistant Clinical Professor of Ophthalmology at California Pacific Medical Center and practices at Pacific Eye Associates in San Francisco. He holds no financial interest in the products and companies mentioned herein. Dr. Tanaka may be reached at (415) 923-3026; ghtanaka@yahoo.com.
1. Maffett MJ, O'Day DM. Cyclodialysis cleft following a scleral tunnel incision.
Ophthalmic Surg. 1994;25:387-388.
2. Parnes RE, Dailey JR, Aminlari A. Hypotonus cyclodialysis cleft following anterior chamber intraocular lens removal. Ophthalmic Surg. 1994;25:386-387.
3. Small EA, Solomon JM, Prince AM. Hypotonus cyclodialysis cleft following suture fixation of a posterior chamber intraocular lens. Ophthalmic Surg. 1994;25:107-109.
4. Terry SA. Cyclodialysis cleft following holmium laser sclerostomy, treated by argon laser photocoagulation. Ophthalmic Surg. 1992;23:825-826.
5. Fellman RL, Starita RJ, Spaeth GL. Reopening cyclodialysis cleft with Nd:YAG laser following trabeculectomy. Ophthalmic Surg. 1984;15:285-288.
6. Krohn J. Cryotherapy in the treatment of cyclodialysis cleft induced hypotony. Acta Ophthalmol Scand. 1997;75:96-98.
7. Gentile RC, Pavlin CJ, Liebmann JM, et al. Diagnosis of traumatic cyclodialysis by ultrasound biomicroscopy. Ophthalmic Surg Lasers. 1996;27:97-105.
8. Park M, Kondo T. Ultrasound biomicroscopic findings in a case of cyclodialysis. Ophthalmologica. 1998;212:194-197.
9. Brandonisio TM, Newman TL. Hypotonous maculopathy and normal visual acuity secondary to post-traumatic cyclodialysis cleft. Optometry. 2002;73:620-625.
10. Joondeph HC. Management of postoperative and post-traumatic cyclodialysis clefts with argon laser photocoagulation. Ophthalmic Surg. 1980;11:186-188.
11. Ormerod LD, Baerveldt G, Sunalp MA, et al. Management of the hypotonous cyclodialysis cleft. Ophthalmology. 1991;98:1384-1393.
12. Brooks AM, Troski M, Gillies WE. Noninvasive closure of a persistent cyclodialysis cleft. Ophthalmology. 1996;103:1943-1945.
13. Brown SV, Mizen T. Transscleral diode laser therapy for traumatic cyclodialysis cleft. Ophthalmic Surg Lasers. 1997;28:313-317.
14. Saha N, MacNaught AI, Gale RP. Closure of cyclodialysis cleft using diode laser. Eye. 2003;17:527-528.
15. Caronia RM, Sturm RT, Marmor MA, et al. Treatment of a cyclodialysis cleft by means of ophthalmic laser microendoscope endophotocoagulation. Am J Ophthalmol. 1999;128:760-761.
16. Kato T, Hayasaka S, Nagaki Y, et al. Management of traumatic cyclodialysis cleft associated with ocular hypotony. Ophthalmic Surg Lasers. 1999;30:469-472.
17. Helbig H, Foerster MH. Management of hypotonous cyclodialysis with pars plana vitrectomy, gas tamponade, and cryotherapy. Ophthalmic Surg Lasers. 1996;27:188-191.
18. Hoerauf H, Roider J, Laqua H. Treatment of traumatic cyclodialysis with vitrectomy, cryotherapy, and gas endotamponade. J Cataract Refract Surg. 1999;25:1299-1301.
