Direct cyclopexy surgery for post-traumatic cyclodialysis
               with persistent hypotony: ultrasound biomicroscopic evaluation

Cyclodialysis is a relatively rare condition usually caused by ocular injury; however, it can also be caused iatrogenically during intraocular surgery. Hypotony maculopathy is the most important complication and the primary reason for visual loss. Clinical diagnosis using gonioscopy may be difficult, and ultrasound biomicroscopy (UBM) can be an alternative. There are different kinds of treatments, and the optimal one remains controversial. Here we describe a case of traumatic cyclodialysis with persistent ocular hypotony treated by direct cyclopexy, as illustrated by UBM performed before and after surgery.

Refractive errors/surgery; Eye injuries/complications; Eye injuries/ultrasonography; Ocular hypotension/etiology; Ciliary body/injuries; Gonioscopy; Tomography, optical coherence/methods; Microscopy/methods; Visual acuity; Case reports; Humans; Male; Adult

Authorship

Fabiola Murta

Department of Ophthalmology, Ocular Trauma section, Universidade Federal de São Paulo, UNIFESP, São Paulo (SP), BrazilUniversidade Federal de São PauloBrazilSão Paulo, SP, BrazilDepartment of Ophthalmology, Ocular Trauma section, Universidade Federal de São Paulo, UNIFESP, São Paulo (SP), Brazil

Somaia Mitne

Department of Ophthalmology, Ultrasound section, Universidade Federal de São Paulo, UNIFESP, São Paulo (SP), BrazilUniversidade Federal de São PauloBrazilSão Paulo, SP, BrazilDepartment of Ophthalmology, Ultrasound section, Universidade Federal de São Paulo, UNIFESP, São Paulo (SP), Brazil

Norma Allemann Correspondence address: Norma Allemann. Rua Olimpíadas, 134 - Conj. 51 - São Paulo (SP) - 04551-000 - Brazil - E-mail: norma.allemann@pobox.com

Augusto Paranhos Junior

Department of Ophthalmology, Glaucoma section, Universidade Federal de São Paulo, UNIFESP, São Paulo (SP), BrazilUniversidade Federal de São PauloBrazilSão Paulo, SP, BrazilDepartment of Ophthalmology, Glaucoma section, Universidade Federal de São Paulo, UNIFESP, São Paulo (SP), Brazil

Correspondence address: Norma Allemann. Rua Olimpíadas, 134 - Conj. 51 - São Paulo (SP) - 04551-000 - Brazil - E-mail: norma.allemann@pobox.com

Disclosure of potential conflicts of interest: F. Murta, None; S. Mitne, None; N. Allemann, None; A. Paranhos Jr, None.

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Figures

Figures (4)

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Figure 1
Color images obtained and 10-MHz ultrasound performed before and after surgery. A) A preoperative color image obtained 2 months after blunt ocular trauma shows retinal folds with peripapillary heaping of the disc margins and tortuosity and dilatation of the retinal vessels. B) Preoperative 10-MHz ultrasound performed 2 months after blunt trauma shows optic disc edema and choroidal thickening. C) A color image obtained 4 days after surgery for direct cycloplegy shows total resolution of the retinal folds and heaping of the disc margins. D) 10-MHz ultrasound performed 4 days after direct cyclopexy shows resolution of optic disc edema.

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Figure 2
. Ultrasound biomicroscopy (UBM) performed at 50 MHz using the immersion technique after blunt trauma. A) Anterior chamber depth of 3.0 mm, vitreous herniation into the anterior chamber (arrow). B) Inferior angle demonstrating apposition of the peripheral iris (black arrow) to the posterior surface of the cornea associated with vitreous prolapse through the pupil (white arrow). C) A suspected cyclodialysis cleft (black arrow) at the 7 o’clock position. D) Ciliary body detachment (cavernous pattern of the suprachoroidal space; black arrow) in 360°.

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Figure 3
A surgical schematic image of direct cyclopexy. A) Frontal view. Following peritomy, 2 lamellar limbus-based scleral flaps were superiorly elevated 4 mm from the limbus while 2 lamellar fornix-based scleral flaps were elevated inferiorly. Incisions were placed 2 mm from the limbus on the remaining inner sclera of each flap, exposing the detached ciliary body. Absence of aqueous humour leakage through the scleral incision was confirmed, followed by fixation of the ciliary body to the scleral spur by interrupted 10-0 nylon sutures in each quadrant and suturing of the scleral flaps and conjunctiva. B) Lateral view: Fixation of the ciliary body to the scleral spur by interrupted 10-0 nylon sutures. C) Surgical view. A limbus-based, 4-mm scleral flap is elevated, a scleral incision is placed 2 mm from the limbus on the remaining sclera, and the exposed ciliary body is fixed to the scleral spur using interrupted 10-0 nylon sutures.

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Figure 4
Ultrasound biomicroscopy performed 3 years after surgery. A) Complete ciliary body attachment (white arrow) with residual inferior corectopia. B) A residual cyclodialysis cleft (black arrow) from the 5 o’clock to the 8 o’clock position with adjacent anterior synechiae. C) Angle recession at the 9-10 o’clock position (arrow).

Figure 1 Color images obtained and 10-MHz ultrasound performed before and after surgery. A) A preoperative color image obtained 2 months after blunt ocular trauma shows retinal folds with peripapillary heaping of the disc margins and tortuosity and dilatation of the retinal vessels. B) Preoperative 10-MHz ultrasound performed 2 months after blunt trauma shows optic disc edema and choroidal thickening. C) A color image obtained 4 days after surgery for direct cycloplegy shows total resolution of the retinal folds and heaping of the disc margins. D) 10-MHz ultrasound performed 4 days after direct cyclopexy shows resolution of optic disc edema.

Figure 2 . Ultrasound biomicroscopy (UBM) performed at 50 MHz using the immersion technique after blunt trauma. A) Anterior chamber depth of 3.0 mm, vitreous herniation into the anterior chamber (arrow). B) Inferior angle demonstrating apposition of the peripheral iris (black arrow) to the posterior surface of the cornea associated with vitreous prolapse through the pupil (white arrow). C) A suspected cyclodialysis cleft (black arrow) at the 7 o’clock position. D) Ciliary body detachment (cavernous pattern of the suprachoroidal space; black arrow) in 360°.

Figure 3 A surgical schematic image of direct cyclopexy. A) Frontal view. Following peritomy, 2 lamellar limbus-based scleral flaps were superiorly elevated 4 mm from the limbus while 2 lamellar fornix-based scleral flaps were elevated inferiorly. Incisions were placed 2 mm from the limbus on the remaining inner sclera of each flap, exposing the detached ciliary body. Absence of aqueous humour leakage through the scleral incision was confirmed, followed by fixation of the ciliary body to the scleral spur by interrupted 10-0 nylon sutures in each quadrant and suturing of the scleral flaps and conjunctiva. B) Lateral view: Fixation of the ciliary body to the scleral spur by interrupted 10-0 nylon sutures. C) Surgical view. A limbus-based, 4-mm scleral flap is elevated, a scleral incision is placed 2 mm from the limbus on the remaining sclera, and the exposed ciliary body is fixed to the scleral spur using interrupted 10-0 nylon sutures.

Figure 4 Ultrasound biomicroscopy performed 3 years after surgery. A) Complete ciliary body attachment (white arrow) with residual inferior corectopia. B) A residual cyclodialysis cleft (black arrow) from the 5 o’clock to the 8 o’clock position with adjacent anterior synechiae. C) Angle recession at the 9-10 o’clock position (arrow).

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Direct cyclopexy surgery for post-traumatic cyclodialysis with persistent hypotony: ultrasound biomicroscopic evaluation

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[1] Correspondence address: Norma Allemann. Rua Olimpíadas, 134 - Conj. 51 - São Paulo (SP) - 04551-000 - Brazil - E-mail: norma.allemann@pobox.com