GRAND ROUNDSGRAND ROUNDS

Denise A. JohnDenise A. John

VEIVEI

1/19/20071/19/2007

CaseCase

HPI: 17 y/o HPI: 17 y/o ♀ s/p trauma OD ~ 2 wks ♀ s/p trauma OD ~ 2 wks earlier awoke in the AM withearlier awoke in the AM with severe severe pain & pain & vision OD. vision OD.

ROS: Headache & nausea x 2 daysROS: Headache & nausea x 2 days

PMHX: Umbilical herniaPMHX: Umbilical hernia

CaseCase POHX: POHX:

Trauma ODTrauma OD HyphemaHyphema Commotio retinaeCommotio retinae Hemorrhagic choroidal detachmentHemorrhagic choroidal detachment

ø Surgery/lasersø Surgery/lasers

FHX: (-)FHX: (-)

SHX: ø Tobacco/ETOHSHX: ø Tobacco/ETOH

Allergies: NKDAAllergies: NKDA

Meds: PF 1% qid OD; stopped atropine 1% a wk earlierMeds: PF 1% qid OD; stopped atropine 1% a wk earlier

CaseCase 20/400 20/400 NI NI VVAscAsc

20/3020/30

Motility: Full OUMotility: Full OU

52 52 IOPIOPAA

1616

Pupils: Moderately dilated & sluggish OD; ø Pupils: Moderately dilated & sluggish OD; ø RAPDRAPD

Differential Differential DiagnosisDiagnosis

HyphemaHyphema Traumatic iritisTraumatic iritis Traumatic glaucomaTraumatic glaucoma

Lens-inducedLens-induced Ghost cellGhost cell Trabecular meshwork damage/Angle recessionTrabecular meshwork damage/Angle recession

Steroid responseSteroid response Closed cyclodialysis cleftClosed cyclodialysis cleft

CaseCase External exam: Unremarkable OUExternal exam: Unremarkable OU

SLE:SLE: OD: 2+ conjunctival injection; corneal OD: 2+ conjunctival injection; corneal

MCE; AC deep & formed with rare cell; MCE; AC deep & formed with rare cell; multiple iris sphincter tears; lens clear & multiple iris sphincter tears; lens clear & centered; trace pigmented vitreous cellscentered; trace pigmented vitreous cells

OS: UnremarkableOS: Unremarkable

DFE DFE

SummarySummary Recent history of blunt trauma OD Recent history of blunt trauma OD

with period of with period of IOP with the IOP with the development of a hemorrhagic development of a hemorrhagic choroidal detachment, optic disc choroidal detachment, optic disc edema, retinal venous engorgement edema, retinal venous engorgement & macular striae now with & macular striae now with IOP. IOP.

What is your diagnosis?What is your diagnosis?

What would you like to do What would you like to do next?next?

CaseCase Assessment: Assessment:

Spontaneous closure of a cyclodialysis Spontaneous closure of a cyclodialysis cleft with cleft with IOP IOP

Plan: Plan: IOP IOP to 32 (alphagan/cosopt/diamox) in clinic to 32 (alphagan/cosopt/diamox) in clinic Sent home on glaucoma gtts/diamox/PF & Sent home on glaucoma gtts/diamox/PF &

atropineatropine F/u 3 daysF/u 3 days

Cyclodialysis: Cyclodialysis: PathophysiologyPathophysiology

Blunt trauma: Blunt trauma: Axial Axial

compression & compression & rapid rapid compensatory compensatory equatorial equatorial expansionexpansion

Cyclodialysis: Cyclodialysis: PathophysiologyPathophysiology

Separation of the Separation of the longitudinal ciliary longitudinal ciliary muscle fibers from muscle fibers from the scleral spurthe scleral spur

Uveal-scleral Uveal-scleral outflowoutflow

CyclodialysisCyclodialysis

UncommonUncommon

Etiology:Etiology: AccidentalAccidental

Blunt ocular traumaBlunt ocular trauma Ocular surgeries involving manipulation of the Ocular surgeries involving manipulation of the

iris tissueiris tissue IntentionalIntentional

Glaucoma managementGlaucoma management

Surgical CyclodialysisSurgical Cyclodialysis Heine,1905: Heine,1905:

Alternative to filtering Alternative to filtering surgery, esp. in aphakic surgery, esp. in aphakic glaucomaglaucoma

Unpredictable resultsUnpredictable results

Complications: Complications: Hemorrhage, Hemorrhage, stripping of stripping of Descemet’s, corneal Descemet’s, corneal damage, tearing of damage, tearing of the iris/ciliary body, the iris/ciliary body, lens injury & vitreous lens injury & vitreous loss & phthisisloss & phthisis

Cyclodialysis: Cyclodialysis: ComplicationsComplications

Hypotony (IOP Hypotony (IOP << 6) 6) Internal filtration, Internal filtration, aqueous production or both aqueous production or both Often stabilizes in a few weeksOften stabilizes in a few weeks Magnitude of hypotony ø proportional to size of Magnitude of hypotony ø proportional to size of

cleftcleft

Variable VVariable VAA

Transudation of protein-rich fluid into the Transudation of protein-rich fluid into the subretinal space in posterior pole subretinal space in posterior pole Statistical association between IOP Statistical association between IOP << 4 & 4 &

VVAA < < 20/200 20/200

Cyclodialysis: Cyclodialysis: Complications Complications

Shallow ACShallow AC Induced hyperopiaInduced hyperopia CataractCataract Choroidal effusionChoroidal effusion Retinal & choroidal foldsRetinal & choroidal folds Engorgement & stasis of retinal veinsEngorgement & stasis of retinal veins CMECME Optic disc edemaOptic disc edema

DiagnosisDiagnosis ClinicalClinical

Gonioscopy Gonioscopy Often small < 4 clock hrsOften small < 4 clock hrs White band (sclera) below the TMWhite band (sclera) below the TM

Ultrasound biomicroscopy (UBM)Ultrasound biomicroscopy (UBM) Resolution Resolution with higher frequencies at the with higher frequencies at the

expense of depth of penetrationexpense of depth of penetration 50MHz transducer50MHz transducer 50 50 μμm m resolutionresolution 5mm penetration5mm penetration

Accurate assessment of Accurate assessment of location & sizelocation & size

Cyclodialysis:Cyclodialysis: Management Management

Goal: Reverse hypotonyGoal: Reverse hypotony

Indications for treatment:Indications for treatment: Hypotonous maculopathy + disc edemaHypotonous maculopathy + disc edema Macular foldsMacular folds Choroidal detachmentChoroidal detachment Corneal edema + worsening visionCorneal edema + worsening vision

Cyclodialysis:Cyclodialysis: Medical Medical

11stst line treatment line treatment

Duration: 6 wksDuration: 6 wksTopical long-acting cycloplegic Topical long-acting cycloplegic

1% Atropine1% Atropine

Corticosteroids ø indicatedCorticosteroids ø indicated

Cyclodialysis: LaserCyclodialysis: Laser Argon laser photocoagulation Argon laser photocoagulation (Joondeph,HC; (Joondeph,HC;

1980)1980) 400-800mW400-800mW 200200μμm spot sizem spot size 0.1-0.2 sec0.1-0.2 sec

Transscleral YAG laser Transscleral YAG laser cyclophotocoagulation cyclophotocoagulation

(Brooks et al.; 1991)(Brooks et al.; 1991) 6 J power6 J power 20 applications20 applications 2-3mm behind limbus2-3mm behind limbus

Cyclodialysis: Surgical Cyclodialysis: Surgical TechniquesTechniques

Ciliochoroidal diathermyCiliochoroidal diathermy

Direct cyclopexyDirect cyclopexy

Indirect cyclopexy (McCannel retrievable suture)Indirect cyclopexy (McCannel retrievable suture)

Iris-base inclusion cyclopexyIris-base inclusion cyclopexy

Anterior scleral buckleAnterior scleral buckle

Vitrectomy/cryotherapy/gas tamponadeVitrectomy/cryotherapy/gas tamponade

Cyclodialysis: Hypotony Cyclodialysis: Hypotony ManagementManagement

Aminlari et alAminlari et al , 2004, described the management of 7 pts , 2004, described the management of 7 pts with a cyclodialysis cleftwith a cyclodialysis cleft

Etiology of cyclodialysis cleftEtiology of cyclodialysis cleft 1 eye: blunt trauma1 eye: blunt trauma 5 eyes: s/p ECCE5 eyes: s/p ECCE 1 eye: s/p trabeculotomy1 eye: s/p trabeculotomy

Duration of ocular hypotony (IOP range 0-6mmHg)Duration of ocular hypotony (IOP range 0-6mmHg) 2 pts: 1-2 wks2 pts: 1-2 wks 3 pts: 3-5 mos3 pts: 3-5 mos 2 pts: > 1yr2 pts: > 1yr

VVA A pretreatment: Range 20/50-20/100pretreatment: Range 20/50-20/100

Cyclodialysis: Cyclodialysis: Hypotony Management Hypotony Management

ManagementManagement 4/7 eyes: Medical tx (atropine 1% BID-TID) 4/7 eyes: Medical tx (atropine 1% BID-TID)

alonealone Hypotony reversed within 1 wkHypotony reversed within 1 wk

2 eyes: 2 treatments of argon laser (1 wk 2 eyes: 2 treatments of argon laser (1 wk apart) due to apart) due to øø response atropine tid-qid response atropine tid-qid

Hypotony reversed in 4 daysHypotony reversed in 4 days

1 eye: Surgical closure (direct cyclopexy)1 eye: Surgical closure (direct cyclopexy) Pediatric pt unable to cooperate at slitlamp for laserPediatric pt unable to cooperate at slitlamp for laser Hypotony reversed POD#1Hypotony reversed POD#1

VVA A post-treatment: Range 20/20-20/60post-treatment: Range 20/20-20/60

Cyclodialysis: Management Cyclodialysis: Management AlgorithmAlgorithm

1. Medical tx2. Laser

3. Repeat laser

Small cleft (< 2 clock hrs)

1. Direct cyclopexy2. Ciliochoroidal diathermy

3. Indirect cyclopexy

Medium cleft (2-4 clock hrs)

1. Direct cyclopexy2. Ciliochoroidal diathermy

Large cleft (> 4 clock hrs)

1. Direct cyclopexy2. Anterior scleral buckle

Ormerod et al, 1991

Cyclodialysis: Cyclodialysis: Management Management

Cyclodialysis cleft may close Cyclodialysis cleft may close spontaneously due to…spontaneously due to… Inflammatory responseInflammatory response hyphemahyphema CycloplegiaCycloplegia

May occur within first 6 wksMay occur within first 6 wks

More common in childrenMore common in children

Cyclodialysis: Cyclodialysis: ManagementManagement

Following resolution, a self-limited Following resolution, a self-limited ocular hypertension is common ocular hypertension is common within the first 2 wkswithin the first 2 wks IOP rarely > 45mmHgIOP rarely > 45mmHg

Miotics are contraindicatedMiotics are contraindicated

Cyclodialysis: Cyclodialysis: PrognosisPrognosis

Vision often improves after hypotony Vision often improves after hypotony is corrected (IOP: 6-12mmHg)is corrected (IOP: 6-12mmHg) Best results with early correctionBest results with early correction Vision may improve rapidly or take Vision may improve rapidly or take

monthsmonths

Delay of treatment > 8 wks Delay of treatment > 8 wks the the risk of losing 1-3 snellen lines of risk of losing 1-3 snellen lines of visionvision

Back to our Back to our patient…patient…

VVAA 20/60; IOP nrl on f/u appt. 20/60; IOP nrl on f/u appt. Tapered pred forte; atropine continued; glaucoma gtts/diamox Tapered pred forte; atropine continued; glaucoma gtts/diamox

stopped stopped

~ 2 wks after IOP normalized, recurrence of ~ 2 wks after IOP normalized, recurrence of IOP (38); IOP (38);

VVAA 20/50 20/50+2+2; glaucoma gtts resumed; PF/atropine ; glaucoma gtts resumed; PF/atropine stoppedstopped

~ 2 wk f/u IOP normalized; V~ 2 wk f/u IOP normalized; VAA 20/25 20/25-2-2; glaucoma gtts ; glaucoma gtts continuedcontinued

Follow-up 3 mosFollow-up 3 mos

Take home points…Take home points… Cyclodialysis cleft should be considered with Cyclodialysis cleft should be considered with IOP in IOP in

setting of blunt trauma. setting of blunt trauma.

Closed cyclodialysis cleft should be considered with Closed cyclodialysis cleft should be considered with IOP IOP and a history of blunt trauma (within 6 wks) and and a history of blunt trauma (within 6 wks) and IOP with IOP with signs of hypotony maculopathy &/or choroidal detachment.signs of hypotony maculopathy &/or choroidal detachment.

Hypotony is the major complication & is responsible for Hypotony is the major complication & is responsible for vision loss.vision loss.

A hypotonous cyclodiaysis cleft without retinopathy does A hypotonous cyclodiaysis cleft without retinopathy does not require treatment.not require treatment.

Goal of treatment is to reverse the hypotonyGoal of treatment is to reverse the hypotony

Medical treatment is the primary form of management for Medical treatment is the primary form of management for the first the first

6 wks.6 wks.

ReferencesReferences

Ormerod et al. Management of a hypotonous cyclodialysis cleft. Ophth Ormerod et al. Management of a hypotonous cyclodialysis cleft. Ophth 1991; 98 (9): 1384-931991; 98 (9): 1384-93

Tran et al. UBM in the diagnosis & management of cyclodialysis cleft. Tran et al. UBM in the diagnosis & management of cyclodialysis cleft. Asian J Ophth, Vol. 4 (3) 2002; 11-15Asian J Ophth, Vol. 4 (3) 2002; 11-15

Hansen et al. Visualized cyclodialysis: an additional option in glaucoma Hansen et al. Visualized cyclodialysis: an additional option in glaucoma surgery. Acta Ophth. 1986; 64: 142-45surgery. Acta Ophth. 1986; 64: 142-45

Joondeph HC. Management of postoperative & post-traumatic cyclodialysis Joondeph HC. Management of postoperative & post-traumatic cyclodialysis clefts with argon laser photocoagulation. Ophth Surg. 1980; 11: 186-88clefts with argon laser photocoagulation. Ophth Surg. 1980; 11: 186-88

Brooks et al. Noninvasive closure of a persistent cyclodialysis cleft. Brooks et al. Noninvasive closure of a persistent cyclodialysis cleft. Ophth.1996; 103: 1943-45Ophth.1996; 103: 1943-45

Aminlari et al. Medical/surgical/laser management of cyclodialysis cleft. Aminlari et al. Medical/surgical/laser management of cyclodialysis cleft. Arch Ophth. 2004; 122; 399-404Arch Ophth. 2004; 122; 399-404

Alward. Color Atlas of Gonioscopy. AAO. 2001Alward. Color Atlas of Gonioscopy. AAO. 2001 BCSC. Glaucoma. AAO. 2004-5BCSC. Glaucoma. AAO. 2004-5 Yanoff. Traumatic Glaucomas. 2Yanoff. Traumatic Glaucomas. 2ndnd Ed. 2004 Ed. 2004 Allingham et al. Shield’s testbook of glaucoma. Traumatic Glaucomas. 5Allingham et al. Shield’s testbook of glaucoma. Traumatic Glaucomas. 5 thth

Ed. 2005Ed. 2005