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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 35-38

Treatment of hypotony maculopathy caused by traumatic cyclodialysis


Department of Ophthalmology, Taipei City Hospital, Taiwan

Date of Web Publication1-Mar-2012

Correspondence Address:
Gow-Lieng Tseng
Department of Ophthalmology, Taipei City Hospital, RenAi Branch, Number 10, Section 4, Ren’ai Road, Da An District, Taipei City 10629
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.1016/j.tjo.2011.12.001

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  Abstract 


A 29-year-old male experienced abrupt visual loss in the left eye following an elastic cord rebounding injury that resulted in ocular hypotony. He received topical atropine and prednisolone eye drops for more than one month without improvement. On examination, his visual acuity was 1.0 OD and counting fingers at 80 cm OS. Initial intraocular pressure (IOP) was 15 mmHg OD and 6 mmHg OS. Gonioscopic evaluation of his left eye revealed a cyclodialysis cleft positioned between 6 and 7 o’clock. A fundus photograph showed signs of hypotony maculopathy including optic disc edema, tortuous vessels, and chorioretinal folds. B-scan ultrasound displayed choroidal thickening and optical coherence tomography (OCT) demonstrated macular edema, subretinal fluid, retinal striae, and choroidal folds. Pars plana vitrectomy and sulfur hexafluoride (SF6) tamponade were performed. After gas absorption, IOP was 11 mmHg OS and remained steady during follow-up. One week after surgery, his visual acuity improved to 0.9. The present case highlights that pars plana vitrectomy with gas tamponade is worth considering for patients with cyclodialysis cleft associated with hypotony maculopathy. Early surgical intervention remains the treatment of choice when hypotony maculopathy and deteriorated vision are noted. Conservative management may be suitable in cases when visual function is not impaired.

Keywords: cyclodialysis, gas tamponade, hypotony maculopathy, vitrectomy


How to cite this article:
Lin CC, Tseng GL, Chen CC, Woung LC, Liou SW. Treatment of hypotony maculopathy caused by traumatic cyclodialysis. Taiwan J Ophthalmol 2012;2:35-8

How to cite this URL:
Lin CC, Tseng GL, Chen CC, Woung LC, Liou SW. Treatment of hypotony maculopathy caused by traumatic cyclodialysis. Taiwan J Ophthalmol [serial online] 2012 [cited 2021 Oct 24];2:35-8. Available from: https://www.e-tjo.org/text.asp?2012/2/1/35/203105




  1. Introduction Top


Cyclodialysis clefts are rare and result from disruption of the ciliary muscle from the scleral spur. Small clefts might close spontaneously, but persistent clefts may result in several complications. Hypotony maculopathy is one of the most severe sequelae that could cause permanent visual loss.[1] We describe a young patient with traumatic cyclodialysis cleft and hypotony maculopathy who was treated successfully with pars plana vitrectomy and gas tamponade alone and suggest this as an alternative treatment plan.


  2. Case report Top


A 29-year-old male suffered from sudden onset of visual loss in the left eye due to an elastic cord rebounding injury in September 2009. He visited the emergency room in another hospital where low intraocular pressure (IOP) of 4 mmHg and subconjunctival hemorrhage in the left eye were initially impressed. Further examination documented a traumatic cyclodialysis cleft and ocular hypotony OS. He received topical atropine and prednisolone eye drops and was followed up in the clinic for more than 4 weeks. Laser photocoagulation was also applied to the cleft, but visual acuity showed no recovery. He was referred to us for further management in November 2009.

The patient’s visual acuity measured 1.0 OD and counting fingers at 80 cm with high hyperopia of 6.0 diopters OS. IOP was 15 mmHg OD and 6 mmHg OS. Slit-lamp evaluation of the left eye found a cleft extending from the position of 6 to 7 o’clock [Figure 1]A, but with a clear lens and a deep and quiet anterior chamber. Gonioscopy confirmed the cyclodialysis cleft associated with an angle recession [Figure 1]B. Fundus photograph showed signs of hypotony maculopathy including papilloedema, tortuous vessels, engorged retinal veins, macular edema, and chorioretinal folds [Figure 1]C. B-scan ultrasound revealed choroidal effusion with reduced axial length of 22 mm [Figure 1]D. Optical coherence tomography (OCT) demonstrated foveal thickening (447 μm), subretinal fluid accumulation, and retinal striae [Figure 1]E. Traumatic cyclodialysis with angle recession and secondary hypotony maculopathy were diagnosed. Because his vision did not improve after the previous conservative treatment, we decided to perform sutured 19-gauge pars plana vitrectomy and 16% sulfur hexafluoride (SF6) tamponade. Postoperatively, it was suggested to him to keep a prone position or down-looking for 1 week.
Figure 1: (A) Slit-lamp examination revealed a cleft at a position of 6–7 o’clock (arrow). (B) Gonioscopy showed a cyclodialysis cleft (white arrow) accompanied by an angle recession (black arrow). (C) Fundoscopic photograph showed hypotony maculopathy of optic disc swelling, macular edema, tortuous vessels, and chorioretinal folds. (D) B-scan echography showed 360° choroidal detachment (arrowhead). (E) Preoperative OCT showed subretinal fluid accumulation (asterisk), retinal folds, and macular thickening (arrows).

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An intraocular pressure spike up to 23 mmHg developed on the 1st postoperative day, but reversed 1 week later after gas absorption. Visual acuity improved dramatically to 0.9 immediately, 1 week after surgery. IOP was around 11 mmHg and remained within normal ranges during further follow-up. We also noted marked resolution of macular edema, tortuous vessels, and retinal folds. The cyclodialysis cleft was completely closed 3 months after surgery. However, mild residual macular wrinkling persisted 3 months later [Figure 2]A. OCT also revealed resolved chorioretinal folds and subretinal fluid [Figure 2]B. Foveal thickness showed great recovery of macular edema from 447 to 240 μm.
Figure 2: (A) At the 3-month follow-up, fundus examination revealed resolution of maculopathy with residual macular striae (arrows). (B) OCT at postoperative 3 months showed marked resolved subretinal fluids, chorioretinal folds (arrows), and macular edema.

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  3. Discussion Top


Hypotony maculopathy was first described in 1955 by Della-porta.[2] It is characterized by hypotony associated with fundus abnormalities, including papilloedema, vascular tortuosity, macular edema, and chorioretinal folds. There are two definitions of hypotony: statistical hypotony can be defined as an IOP < 6.5 mmHg and clinical significant hypotony represents the condition where the IOP is low enough to result in visual loss.[3]

Hypotony maculopathy can result from any condition leading to reduced IOP. Most cases of ocular hypotony occur postoperatively. It is usually seen with a wound leak or an overfiltering bleb, particularly with adjunctive mitomycin C, which has been reported to occur in up to 20% of cases of glaucoma filtering surgery.[4] Other hypotonous conditions can be observed after trauma, such as cyclodialysis cleft, iridocyclitis, ciliochoroidal detachment, or scleral rupture. In addition, systemic diseases such as dehydration, diabetic coma, uremia, and myotonic dystrophy would induce bilateral hypotony. Miscellaneous forms of hypotony are also known to follow ciliary body hypoperfusion, carotid occlusion, temporal arteritis, central retinal artery, or vein occlusion.[3]

Cyclodialysis establishes an abnormal pathway for the aqueous humor to reach the suprachoroidal space and causes secondary hypotony. However, the magnitude of the hypotony is not proportional to the size of the cyclodialysis cleft.[5] Treatment of cyclodialysis induced hypotony should start once the cyclodialysis cleft is identified. Conservative management includes the trial of topical 1% atropine for 6 to 8 weeks.[1] If medical treatment is ineffective, noninvasive management with laser photocoagulation applied to the cleft should be attempted. Transscleral diathermy and transconjunctival cryotherapy have been reported to induce an inflammatory reaction to enhance cleft closure. Surgical intervention is recommended if conservative treatment fails or moderate-to-large clefts are encountered. Conventional repairs include external plombage and direct cyclopexy.[1],[6] Direct surgical cyclopexy of the ciliary body to scleral spur was presented in a case series of 29 patients in which cleft closure was achieved in 28 cases and one case was left with a small residual cleft but no ocular hypotony.[7]

Novel techniques for surgical therapy have recently been proposed. One procedure described anterior buckling using a silicone rod to repair a hypotonous cyclodialysis cleft. This avoids intraocular surgery, but a risk of globe perforation must be considered.[8] In another procedure, a capsular tension ring or intraocular lens was reportedly successfully placed in the ciliary sulcus to repair a 360° traumatic cyclodialysis cleft,[9],[10]; however, there is a potential risk of ciliary body damage, erosion, hemorrhage, and pain from the compressive effect of the haptics. In another technique, vitrectomy, cryotherapy, and gas tamponade were mechanical appositions by the gas bubble, and scar induction by cryotherapy.[11] Although this technique provided an alternative approach, intraocular surgery may include complications and risks. Finally, gas tamponade with cryotherapy was presented as a less invasive method which conducts an intravitreal injection of gas and is relatively simple to perform. It seems to improve the efficacy of cryotherapy alone providing a mechanical apposition of the ciliary muscle to the sclera due to a gas bubble and allowing a better scar induction. However, patients will experience uncomfortable pain after cryotherapy, although it is effective in large clefts.[12]

Currently, sutureless pars plana vitrectomy is easier to perform even with 23-gauge or 25-gauge and the surgical wound is small and self-sealed. This sutureless technique greatly reduces surgical risks and increases benefits for patients with less discomfort, fewer complications, and quicker postoperative recovery. However, some complications such as postoperative wound and gas leakage, hypotony, and a possible increased rate of endophthalmitis may be related to unsutured sclerotomies.

In our case, our patient had a small cyclodialysis; however, he suffered severe hypotony maculopathy that reduced visual acuity significantly and did not improve after 4 weeks of conservative management. It has been suggested that surgical treatment should be delayed until 6 months after maculopathy develops because spontaneous recovery may occur.[13] Nevertheless, we considered the young age of this patient and a need to avoid irreversible wrinkling or fibrosis of the retina, and early normalization of IOP will result in significant improvement in visual acuity.[14] Therefore, we performed aggressive intervention with pars plana vitrectomy and SF6 tamponade in the 5th week after trauma in view of the patient’s visual prognosis. Sutured 19-gauge pars plana vitrectomy was arranged for him to avoid postoperative gas leakage and hypotony. We did not apply gas tamponade alone in our case, due to his young age, and because the vitreous does not liquefy, the gas bubble may not provide a sufficient internal tamponade effect for the detached ciliary body to approximate the sclera.[15] In addition, the gas bubble in the vitreous base may induce retinal traction and subsequent retinal detachment. Therefore, we combined vitrectomy and gas tamponade, although it may also be efficient to reverse hypotonous cyclodialysis only by gas tamponade in patients with liquefied vitreous. Furthermore, cryotherapy was not applied to this patient because the cyclodialysis cleft is small and we avoided this procedure to reduce postoperative discomfort. In a cleft with moderate–large extension (>90°), vitrectomy as well as gas tamponade may be modified by additional cryotherapy to induce better scar formation and advance cleft closure. We also suggested that our patient keep a prone position or a looking-down position postoperatively due to his severe hypotony maculopathy which resulted in profound macular folding; therefore, the prone position would help the gas bubble to tamponade the macular area and smooth the macula. In addition, because his cyclodialysis cleft is small, we underwent complete fluid–air exchange and full gas retention in the vitreous cavity that was adequate to tamponade the cleft at 6–7 o’clock positions and provide a mechanical apposition for it. Hoerauf et al[11] presented a case with the cleft positioned from 4 to 9 o’clock (170°) and the patient was told to remain in a supine position for 5 days postoperatively. Ceruti et al[12] described a cleft which was extending from the 6 to 12 o’clock positions and the patient was asked to lie on his left side for 5 days after surgery. Kaori et al[13] reported four cases with large clefts (180–360°): the patients were placed in a prone position on the day of surgery and in a supine position for the following 6 days. According to these studies, a supine position may be more suitable if a large cleft exists. In addition, our patient with a small cleft obtained a good outcome even in a prone position.

In conclusion, it is important to identify a cyclodialysis cleft in secondary hypotony maculopathy after blunt trauma. Pars plana vitrectomy with gas tamponade is worth considering for patients with cyclodialysis associated with hypotony maculopathy. Early surgical intervention is essential for patients with hypotonous cyclodialysis who show no progressive improvement with conservative treatment. We suggest pars plana vitrectomy and gas tamponade in cases with small cyclodialysis. This can be modified by performing an additional step of cryotherapy in a large cleft to induce inflammatory reaction and promote cleft closure. In our patient, postoperative IOP was favorable and visual acuity showed marked improvement with a short recovery period. Conservative management may be indicated when visual function is not impaired.



 
  References Top

1.
Alexander SL, Keith B. Cyclodialysis cleft: causes and repair. Curr Opin Ophthalmol 2010;21:50–4.  Back to cited text no. 1
    
2.
Dellaporta A. Fundus changes in postoperative hypotony. Am J Ophthalmol 1955;40:781–5.  Back to cited text no. 2
    
3.
Vital PC, Enyr SA. Hypotony maculopathy. Acta Ophthalmol Scand 2007;85:586–97.  Back to cited text no. 3
    
4.
Costa VP, Wilson RP, Moster MR, Schmidt CM, Gandham S. Hypotony maculopathy following the use of topical mitomycin C in glaucoma filtration surgery. Ophthalmic Surg 1993;24:389–94.  Back to cited text no. 4
    
5.
Aminlari A, Callahan CE. Medical, laser, and surgical management of inadvertent cyclodialysis cleft with hypotony. Arch Ophthalmol 2004;122:399–404.  Back to cited text no. 5
    
6.
Kutschera E. A simplified procedure in the treatment of the hypotony-syndrome. Klin Monatsbl Augenheilkd 1975;166:834–5.  Back to cited text no. 6
    
7.
Kuchle M, Naumann GO. Direct cyclopexy for traumatic cyclodialysis with persisting hypotony. Report in 29 consecutive patients. Ophthalmology 1995; 102:322–33.  Back to cited text no. 7
    
8.
Mandava N, Kahook MY, Mackenzie DL, Olson JL. Anterior scleral buckling procedure for cyclodialysis cleft with chronic hypotony. Ophthalmic Surg Lasers Imaging 2006;37:151–3.  Back to cited text no. 8
    
9.
Yuen NS, Hui SP, Woo DC. New method of surgical repair for 360-degree cyclodialysis. J Cataract Refract Surg 2006;32:13–7.  Back to cited text no. 9
    
10.
Mardelli PG. Closure of persistent cyclodialysis cleft using the haptics of the intraocular lens. Am J Ophthalmol 2006;142:676–8.  Back to cited text no. 10
    
11.
Hoerauf H, Roider J, Laqua H. Treatment of traumatic cyclodialysis with vitrectomy, cryotherapy, and gas endotamponade. J Cataract Refract Surg 1999; 25:1299–301.  Back to cited text no. 11
    
12.
Ceruti P, Tosi R, Marchini G. Gas tamponade and cyclocryotherapy of a chronic cyclodialysis cleft. Br J Ophthalmol 2009;93:414–6.  Back to cited text no. 12
    
13.
Kaori T, Yukihiko S, Mitsuru N. Four cases of hypotony maculopathy caused by traumatic cyclodialysis and treated by vitrectomy, cryotherapy, and gas tamponade. Graefe’s Arch Clin Exp Ophthalmol 2006;244:855–8.  Back to cited text no. 13
    
14.
Kato T, Hayasaka S, Nagaki Y, Matsumoto M. Management of traumatic cyclodialysis cleft associated with ocular hypotony. Ophthalmic Surg Lasers 1999; 30:469–72.  Back to cited text no. 14
    
15.
Helbig H, Foerster MH. Management of hypotonous cyclodialysis with pars plana vitrectomy, gas tamponade, and cryotherapy. Ophthalmic Surg Lasers 1996;27:188–91.  Back to cited text no. 15
    


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