|
 
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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 58
| Issue : 4 | Page : 274-279 |
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Current concepts in the management of cyclodialysis
Vijayalakshmi A Senthilkumar, Sharmila Rajendrababu
Department of Glaucoma, Aravind Eye Hospital and Postgraduate, Institute of Ophthalmology, Madurai, Tamil Nadu, India
| Date of Submission | 22-Jun-2020 |
| Date of Acceptance | 07-Aug-2020 |
| Date of Web Publication | 16-Dec-2020 |
Correspondence Address:
Dr. Vijayalakshmi A Senthilkumar
Aravind Eye Hospital and Postgraduate, Institute of Ophthalmology, Anna Nagar, Madurai - 625 020, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjosr.tjosr_77_20
Cyclodialysis clefts are rare. The most common reason for presentation is blunt ocular trauma followed by various iatrogenic interventions. Although gonioscopy is the gold standard technique, diagnosis is particularly challenging, and various noninvasive techniques such as ultrasound biomicroscopy and the newer anterior segment swept-source optical coherence tomography have been found effective. The management of cyclodialysis clefts should be conservative initially followed by a variety of nonsurgical and surgical modalities to achieve closure. In this article, we report the most recent developments in the diagnosis and surgical and nonsurgical treatment strategies of cyclodialysis cleft. An extensive literature search was done using PubMed and Google Scholar with the search terms such as cyclodialysis cleft, ocular hypotony, hypotony maculopathy, cyclopexy, and cyclotamponade.
Keywords: Blunt injury, cyclodialysis cleft, cyclopexy, cyclotamponade, hypotony maculopathy, ocular hypotony
How to cite this article:
Senthilkumar VA, Rajendrababu S. Current concepts in the management of cyclodialysis. TNOA J Ophthalmic Sci Res 2020;58:274-9 |
| Introduction | |  |
Cyclodialysis clefts are areas of disinsertion of the meridional ciliary muscle fibers from their attachment at the scleral spur, allowing direct communication between the anterior chamber and the ciliochoroidal space. The two most common causes include blunt trauma or surgery, particularly following cataract surgeries.[1] It is a rare clinical finding, and therefore, reports on the management and outcomes of various treatment modalities are limited in the literature. In addition, ocular hypotony can make the cleft repair technically challenging. The outcomes vary widely depending on the extent of the clefts and the methods used to treat them. In this review article, an extensive literature search was done in PubMed and Google Scholar using the terms cyclodialysis cleft, ocular hypotony, hypotony maculopathy, cyclopexy, and cyclotamponade. Relevant articles published in English language were reviewed.
| Causes of Cyclodialysis Cleft | | |
A cyclodialysis cleft, first described by Fuchs in 1900, is an uncommon finding.[2] Previously, cyclodialysis was intentionally caused during an obsolete surgical technique for treating glaucoma. Nowadays, it is mainly caused by severe blunt ocular trauma, which causes momentary axial compression and a rapid compensatory equatorial expansion that stretches the ocular tissue, resulting in separation and tearing of the tissue.[3] The prevalence of cyclodialysis clefts following blunt ocular trauma is 2% to 5% or higher.[4] These clefts have been described following extracapsular cataract surgery, phacoemulsification, intraocular lens insertion, after phakic intraocular lens (IOL) removal, displacement of an angle-supported anterior chamber IOL, filtration surgery, iridectomy, and transscleral fixation of IOL.[5] Sometimes, traumatic cleft may open up several years following surgery, especially phacoemulsification.[6] The patient can present with unexplained hypotony after seemingly uncomplicated surgery. The various causes of cyclodialysis cleft are given in [Table 1].
| Ocular Hypotony | | |
Cyclodialysis frequently results in symptomatic ocular hypotony from the direct communication formed, which allows unrestricted uveoscleral flow into the suprachoroidal space. Cyclodialysis clefts mostly recover spontaneously (especially if they involve <90° of the ciliary body [CB]) or with conservative management (1% atropine sulfate twice a day for 6–8 weeks).[7],[8] Persistent cyclodialysis results in a shallow anterior chamber, ciliochoroidal detachment, ocular hypotony, and hypotony maculopathy with loss of vision. The term hypotony maculopathy indicates the inward collapse of the scleral wall caused by ocular hypotony. During initial stages of hypotony, the decrease in visual acuity is mainly due to chorioretinal folds in the macular area, with distortion and malalignment of the retinal photoreceptors [Figure 1]a. This entity is almost reversible with the stabilization of intraocular pressure (IOP) to the physiological level, and the folds may disappear completely. However, in cases of prolonged or chronic hypotony, pigmented lines resulting from changes in the retinal pigment epithelium may persist and decrease the final visual acuity.[9] | Figure 1: (a) Fundus photo showing disc edema with blurred disc margins and chorioretinal folds in the macula (white arrowhead). (b and c) Ultrasound biomicroscopy image showing cyclodialysis cleft with a clear communication between anterior chamber and suprachoroidal space (white arrowhead)
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| Evaluation of Cyclodialysis Clefts | | |
The right localization and accurate estimation of the extent and number of clefts are imperative for successful outcome of cleft repair surgeries. Slit-lamp examination using a gonioscope has been the most common method to confirm the presence of clefts.[10] However, this modality cannot be applied in patients with hyphema, corneal opacity, and excessive hypotony after trauma or surgery. Gonioscopy in a hypotonous globe may easily overlook the presence of a cleft, and it can be easily visualized after an intracameral injection of viscoelastic at the slit lamp.[10]
High-resolution ultrasound biomicroscopy (UBM) increases the chances of identification and objective quantification of the clefts, so as to decide the treatment strategy.[11] This modality has been used to diagnose and identify the location of a cyclodialysis cleft in eyes with ocular hypotony and media opacities when a cleft was not visible on gonioscopy [Figure 1]b, [Figure 1]c. It is also very helpful in the postoperative assessment after surgical closure of the cleft.[12]
The newer version of anterior segment swept-source optical coherence tomography (OCT) can provide 360° as well as a three-dimensional view of the CB cleft, helping in exact localization and definition of the cleft.[13] Its advantage over UBM is that it is capable of producing higher resolution images without requiring ocular contact. It is easily performed and, while more comfortable for the patient, possesses the disadvantage of poor penetration of opaque tissues.[14] Intraoperatively, gonioscopy is commonly used such as the Mori upright surgical gonio lens, the Koeppe diagnostic gonio lens, or the Swan Jacob gonioprism to accurately identify the location of the cyclodialysis cleft as well as to guide the placement of sutures.[15]
| Management of Cyclodialysis Cleft | | |
The main goal of treatment is to close the cleft, restore the apposition of the CB to the sclera and consequently increase IOP, improve visual acuity, and prevent further complications, such as permanent visual loss.
Medical management with cycloplegics is often the first line of treatment, especially early in the course or when the hypotony is not visually debilitating and no permanent sequelae of hypotony have occurred. Further, semi-conservative methods such as laser photocoagulation, transscleral diathermy, and cryotherapy are indicated in cases of small clefts [Table 2]. There are many case reports on the surgical management of cyclodialysis but very few case series on surgical cleft repair, the largest being those of Hwang et al. (32 eyes of 31 patients) and Kuchle and Naumann (29 eyes).[3],[12]
| Medical Treatment | | |
Long-acting cycloplegic agents such as 1% atropine sulfate and topical steroid eyedrops play an important role as the initial treatment strategy in these patients. While medical treatment of cyclodialysis clefts has generally been disappointing, the use of atropine 1% for 6–8 days has been reported to close small clefts. Ormerod et al. have reported that 1% atropine sulfate twice daily can close the cleft through relaxation of the ciliary muscle, allowing the apposition of the detached meridional ciliary muscle to the sclera.[7] This process is more likely to be effective in small clefts where the surface area of detached CB is small. This approach has been shown to be effective, and the course of treatment can be as long as 6–8 weeks. It has also been suggested that the reduction of postoperative steroids may facilitate inflammatory adhesion at the cleft site.[7]
| Laser Treatment | | |
External and internal laser-based techniques received recognition in the 1990s. A number of laser photocoagulation techniques have been employed to achieve noninvasive cleft closure. Argon laser photocoagulation (ab-interno) has been reported to be effective in small clefts (<2 clock hours).[16] Argon laser (532 nm) burns are applied using a gonioscopy lens within the cleft site. The recommended spot size is 300–500 μm, duration of 0.3–0.5 s, and the power ranged between 800 and 1000 mW. The number of burns is approximately 40–50 shots. The resultant localized inflammatory response encourages closure.[17]
More recently, the use of transscleral diode photocoagulation has been reported. A double row of five applications at 1500 mW and 1500 ms applied over the cleft site using the G probe has been suggested.[18] It is thought that the mechanism of action of the diode laser involves the creation of a localized inflammatory reaction similar to argon photocoagulation or cryopexy. The use of a transscleral YAG laser cyclophotocoagulation has also been reported to be an effective method of treating a cyclodialysis cleft.[19] The laser is delivered through noncontact method with a defocus setting using two rows of application. However, these laser techniques have unpredictable and suboptimal outcomes, a series reporting only 18.8% success rates.[20] Hence, they may be indicated for small clefts when the patient is not fit or unwilling for surgery. They may also be attempted in cases with partial cleft closure. Intraoperative lasers can also be attempted additionally during ab-interno fixations.
| Transscleral Diathermy | | |
Transscleral diathermy involves the creation of a partial-thickness scleral flap before the application of a diathermy probe. The technique involves creating a partial-thickness scleral flap before the application of the diathermy treatment in the vicinity of the cleft.[21] The mechanism of action is based on the principle of inducing a localized thermal burn and a secondary inflammatory reaction similar to argon laser photocoagulation. Scleral ectasia and lens damage have been reported with these techniques.[22]
| Cryotherapy | | |
Cryotherapy application has achieved popularity in recent times because this technique has the advantage of decreased damage to the sclera. Using a cryotherapy probe 2–3 mm from the limbus, a series of overlapping applications can be performed transconjunctivally (temperature approximately −50°C to −60°C).[23]
| Surgical Management | | |
The first report of the surgical repair of a traumatic cyclodialysis was by Vannas and Boerkenheim in 1952.[24] The principles behind the surgical repair include the obliteration of the cyclodialysis space and apposition between the sclera and the wall of the CB. Surgical repair appears to be the option for moderate to large clefts where initial laser photocoagulation or other noninvasive approaches have proven ineffective.
There are several known methods, named as direct cyclopexy, indirect cyclopexy, external suture cyclopexy, internal cyclopexy, and pneumocyclopexy, based on each author's experience and convenience of performing. When sutures solely appose the detached CB to the sclera, based on whether suturing being an ab-externo or ab-interno technique, they can be termed as “exocyclopexy” and “endocyclopexy,” respectively. On the other hand, when tamponade by an extraneous substance such as gas or oil acts as the primary mechanism to fixate the cleft, the corresponding ab-externo and ab-interno techniques have been named as “exocyclotamponade” and “endocyclotamponade,” respectively[14] [Table 3].
| Direct Exocyclopexy (Direct External Suture Fixation) | | |
Cyclopexy is the fixation of the detached CB onto the physiological scleral bed. Direct cyclopexy is often the definitive procedure in cases where conservative management has failed to close the cleft.[14] Full-thickness (Mackensen and Corydon technique) or partial-thickness (Naumann and Volcker technique) flaps have been described, depending on the size and extent of the cyclodialysis cleft.[3],[25] The most commonly performed surgical approach of direct cyclopexy involves raising a partial-thickness scleral flap over the cyclodialysis cleft. The cleft is directly visualized by creating a full-thickness incision under the partial-thickness scleral flap. The CB can then be sutured to the scleral spur to close the cleft, and the partial-thickness scleral flap is finally sutured.[3],[14],[25]
Küchle and Naumann reported the closure of clefts in 28 of 29 eyes operated by direct cyclopexy.[3] Ioannidis et al. reported a 50% success rate after one surgical intervention and suggested that larger or multiple clefts may require more than 1 intervention.[26] Agrawal and Shah reported the combined success of cryotherapy and direct cyclopexy to be 94%.[27] Possible complications of direct cyclopexy include intraocular hemorrhage, endophthalmitis, cataract, vitreous loss, retinal detachment, wound dehiscence, anterior segment ischemia, and secondary glaucoma due to peripheral anterior synechiae.
| Indirect Exocyclopexy (Indirect External Suture Fixation) | | |
Chadha et al. described the technique of applying transcorneal sutures to pass radially from the limbus, iris root, and detached CB to be tied over the scleral surface.[28] This technique is a modification of the McCannel retrievable suture technique.[29] Although this technique appears to be safer than direct cyclopexy, permanent damage to the angle structures may lead to secondary glaucomas. Although cyclopexy is the treatment of choice for cleft repair, the surgeon should always anticipate the short- and long-term complications of multiple suture pass along the entire circumference of the cleft.
| Endocyclopexy (Internal Suture Fixation) | | |
These techniques are performed in such a way where the sutures are applied from inside-out manner without the need for scleral cutdown. Gupta et al. described the technique in which, after lifting a partial-thickness scleral flap over the detached CB, a continuous, loop-type suturing is carried out from the opposite clear corneal incision, which on tightening causes zipper closure of the entire cleft circumference.[30] Wang et al. described the technique of “multiple-suture endocyclopexy” in which pars plana lensectomy and limited anterior vitrectomy are first done, followed by inside-out suturing of the clefts from the opposite port.[31] However, these suturing techniques need prior/concomitant lensectomy and so IOL power calculations to be done based on either the preinjury status or the fellow eye biometry in order to avoid postoperative refractive surprise.[14]
| Exocyclotamponade with Scleral Buckle | | |
Jürgens and Pujol and Inukai et al. proposed the idea of anterior buckling for the repair of hypotonous cyclodialysis clefts using a silicone rod under a partial-thickness scleral flap to provide an outside-in indirect tamponading effect to the detached CB.[32],[33] However, this may result in a lot of complications such as foreign body sensation, Dellen formation, visually significant astigmatism, cosmetic disfigurement, and ultimately requiring removal of the buckle.
| Endocyclotamponade with Intraocular Lens/Capsular Tension Ring/capsular Tension Segment | | |
The use of haptics of rigid IOLs, capsular tension ring (CTR), and capsular tension segment to achieve internal apposition (internal cerclage) of the CB to sclera has recently been reported.[34],[35] Yuen et al. and Mardelli et al. reported the effective management of a 360° cyclodialysis cleft by standard phacoemulsification, followed by insertion of a CTR sutured with 10-0 Prolene at two points to the sclera.[34],[35] At present, there are insufficient reports to estimate the efficacy of this approach. In another report, a PMMA lens was inserted in the sulcus and rotated to appose an area of CB over the cleft to adjacent sclera achieving cleft closure in a patient undergoing cataract surgery with a known cleft.[36] However, there is always a potential risk of CB damage, erosion, hemorrhage, and pain from the compressive effect of the haptics using this approach. The main advantage of all these ab-interno techniques is the ability to treat multiple concurrent ocular injuries such as iridodialysis and cataract at the same sitting and helps obtain better postoperative visual outcomes.[14]
| Endocyclotamponade with Gas/Oil | | |
Ceruti et al. reported the successful resolution of a large cleft using gas endotamponade with a single bubble of 20% sulfur hexafluoride (SF6) in conjunction with cryotherapy.[37] This technique has been reported to successfully treat a very large cleft extending for 6 clock hours. Twelve overlapping applications of cryotherapy were applied for 20 s at − 80°C. The patient received a single bubble of (0.5 ml) of 20% sulfur hexachloride–air mixture through the pars plana, and the patient was advised to posture on his side for 5 days to achieve endotamponade. The idea was to allow the cleft to be opposed by mechanical means (using endotamponade for 5 days), in the form of the gas bubble, and scar induction from the cryotherapy. The technique can be modified with the additional step of performing a pars plana vitrectomy.[38] However, this technique is more invasive and adds the additional risks associated with vitreoretinal surgery. It is also worth pointing out that this is likely to work only if gas is injected in the posterior segment that has an intact posterior capsule, as gas in the anterior segment is more likely to exit through the cleft maintaining its patency.[39]
Factors affecting the outcomes of surgical intervention are summarized in [Table 4].
| Postoperative Care | | |
When undertaking any procedure to reattach the cyclodialysis cleft, it is important to have close monitoring of IOP in the postprocedure period. It has been well documented in the literature that the IOP is unpredictable and has a tendency to be very high in the 1st week following the procedure.[14] This IOP “spike” is in fact an objective evidence that the cleft has been successfully closed as a result of which the aqueous humor that was previously bypassing the normal drainage pathway through the cyclodialysis cleft is now diverted back to drain through the trabecular meshwork. In cases of cyclodialysis cleft following ocular trauma, it is also important for treating clinicians to understand the residual functional damage to the trabecular outflow mechanism. Therefore, long-term monitoring of IOP is mandatory.
| Conclusion | | |
Cyclodialysis is a vision-threatening ocular injury which is difficult to treat and refractory to medical therapy. The management of cyclodialysis clefts requires a careful and logical approach. Investigations such as UBM and AS-OCT/swept source-OCT aid in the diagnosis and treatment of cyclodialysis by determining its extent and exact location, thus guiding the surgeon during surgical repair. In addition, it aids in the evaluation of anatomical surgical success. Surgical repair is often necessary but can be technically difficult and challenging. Conservative (medical) and noninvasive managements (laser, diathermy, and cryotherapy) appears to be the best approach initially, followed by more invasive surgical interventions (cyclopexy and cyclotamponade) for recalcitrant hypotony. Patients must be kept fully informed of the possible risks and benefits of treatment throughout their management. A detailed literature review has failed to identify a clear “gold standard” treatment protocol, and multiple techniques have been described. Until vigorous studies and long-term follow-up data are available, management will continue to be decided by the local availability of imaging, equipment, and expertise.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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