Visualization and Treatment of a Cyclodialysis Cleft Using Ocular

Endoscope Technology

Annie Y. Chan M.D.J. Matthew Rouse M.D.

Mahmoud A. Khaimi M.D.

Dean McGee Eye InstituteUniversity of Oklahoma

The authors have no financial interest in the subject matter of this e-poster.

Purpose

• To report a novel method for definitive diagnosis and primary closure of a chronic cyclodialysis cleft using intraocular endoscopy and diode endolaser photocoagulation in a child who sustained blunt ocular trauma.

Introduction• A cyclodialysis cleft represents a separation of ciliary muscle

fibers from its insertion into the the scleral spur, ultimately leading to hypotony from a direct communication between the anterior chamber and suprachoroidal space.1 These clefts are most commonly caused by blunt ocular trauma, but are also seen after intraocular surgical manipulation.

• Definitive diagnosis with non-invasive techniques such as gonioscopy and ultrasound biomicroscopy (UBM) requires patient cooperation and can be difficult due to hypotony and collapse of the anterior chamber and angle. Utilization of anterior segment optical coherence tomography has been described in a case study,2 but this method also needs adequate patient cooperation.

• Methods of treating cyclodialysis clefts may also be limited by the size of the cleft they can repair or may carry undesirable complications such as surrounding tissue damage.

Case Presentation• An 8 year old boy with a history of blunt trauma to the right eye

was initially evaluated and treated medically for a suspected cyclodialysis cleft. He was referred for further evaluation because of persistent visual reduction and hypotony despite this treatment.

• Examination of his right eye revealed a best corrected visual acuity of 20/125 with mild myopia. IOP was 3 mmHg and a relative afferent pupillary defect of the right eye was noted.

• Anterior segment exam revealed a shallow anterior chamber and early posterior capsular lenticular changes. Gonioscopy was attempted, but no angle structures could be visualized due to ocular hypotony. There were no significant anterior findings in the left eye.

Case Presentation

• The decision was made to proceed with an examination under anesthesia (EUA) including endoscopic evaluation of the ocular angle structures. Consent was also obtained from the patient’s parents for possible endoscopic laser treatment to any area of cyclodialysis cleft located on exam.

Posterior Segment ODFundoscopic exam of the right eye revealed macular striae with surrounding retinal edema (orange arrows) and marked optic nerve head edema (white arrow).

Fundoscopic exam of the left eye was unremarkable.

Ultrasound Biomicroscopy OD

UBM was attempted during the EUA and did not definitively locate or demonstrate the extent of the suspected cyclodialysis cleft. Findings included shallow choroidals extending 360° (small arrows) and an area suggestive of but not conclusive for a cyclodialysis cleft (large arrow).

Surgical Technique for EUAand Treatment

• A paracentesis was then made at the limbus and the anterior chamber was reformed with viscoelastic.

• Gonioscopy was repeated, which identified a potential area for a cleft at the 7:30 position.

• A clear corneal incision was made at the 3 o’clock position and the endoscope handpiece was placed into the anterior chamber, allowing direct visualization of the angle.

• The cyclodialysis cleft was clearly observed with the endoscope and noted to extend approximately one clock hour temporally.

• Angle recession was also observed 360°.• Standard endoscopic photocoagulation was applied to

the area of the cyclodialysis cleft, resulting in shrinkage of the iris at the iris root.

Results• Three weeks after the

procedure, the patient’s IOP increased to 40 mmHg, signifying closure of the cleft (figure left).

• Topical and oral IOP-lowering agents were initiated.

• Five months postoperatively, his IOP was 16mmHg while on topical timolol 0.5% once daily. His BCVA was 20/25 with mild hyperopic correction.

Top: Deepening of the anterior chamber after endoscopic photocoagulation.Bottom: Gonioscopy confirming closure of the cyclodialysis cleft.

Discussion• This case demonstrates how intraocular

endoscopy can be used to definitively diagnose and demonstrate the extent of a cyclodialysis cleft through direct visualization.

• Endolaser photocoagulation can also be applied at the same time to safely close the cyclodialysis cleft with minimal discomfort or risk of damage to surrounding structures.

• Endoscopy with endolaser photocoagulation offers a promising method of diagnosing and treating cyclodialysis clefts, particularly in the pediatric population.

Diagnostic and Treatment Options for Cyclodialysis Clefts3,4

Indirect, Non-invasive visualization• Gonioscopy

• UBM

Indirect, Non-invasive visualization• Gonioscopy

• UBM

Direct, invasive visualization Intraocular Endoscopy

Direct, invasive visualization Intraocular Endoscopy

Non-incisional Treatment

• Gonioscopic laser photocoagulation

• Transscleral diode or YAG laser

• Cryotherapy

Non-incisional Treatment

• Gonioscopic laser photocoagulation

• Transscleral diode or YAG laser

• Cryotherapy

Medical Management

• Mydriatics (e.g. Atropine)

Medical Management

• Mydriatics (e.g. Atropine)

Incisional Treatment• Cyclopexy• Endolaser

photocoagulation •Gas tamponade

Incisional Treatment• Cyclopexy• Endolaser

photocoagulation •Gas tamponade

Blue arrows: First-line management. *Consider incisional treatment for large clefts.Red arrows: If medical treatment is unsuccessful or definitive diagnosis has not been made, a direct diagnostic approach may be considered.

Suspected Cyclodialysis cleft

Suspected Cyclodialysis cleft

*

References1. Ioannidis AS, Barton K. Cyclodialysis cleft: causes and repair.

Current Opinion in Ophthalmology. 2010;21(2): 150-54.2. Mateo-Montoya A, Dreifuss S. Anterior Segment Optical

Coherence Tomography as a Diagnositic Tool for Cyclodialysis Clefts. Arch Ophthalmol 2009; 127:109-110.

3. Aminlari A, Callahan CE. Medical, laser, and surgical management of inadvertent cyclodialysis cleft with hypotony. Arch Ophthalmol 2004; 122:399-404.

4. Omerod LD, Baerveldt G, Sunalp MA, Riekhof FT. Management of the hypotonous cyclodialysis cleft. Ophthalmology 1991; 98(9):1384-93.