Treatment of Post-traumatic Hypotony Related to Cyclodialysis Cleft: Our Experience in Two Cases


ABSTRACT

The Authors present two different surgical approaches in the treatment of hypotony following post-traumatic cyclodyalisis clefts. Cyclodialysis cleft is a rare post-traumatic complication, often difficult to treat, in spite of multiple surgeries.

Case reports:

A 29 YO male patient developed cyclodialysis cleft after a penetrating oculat trauma in his RE (a fragment of nail shot through the superior paralimbal cornea, iris root and ciliary body, with small impact site on the pre-equatorial retina at 11 hs). One single 10/0 nylon suture had been applied to the corneal wound after FB extraction on the same day of the trauma. 6 weeks after suture IOP in the RE was still fluctuating between 4 and 6 mm Hg. His vision had dropped to 20/40, with a 6D myopic shift. Classic signs of ocular hypotony could be documented with OCT and B-scan US: choroidal thickening, papilledema and radial retinochoroidal folds, with no improvement with medical therapy (topical cycloplegics and systemic steroids) taking place. At the ultrasound examination of the anterior segment. On post-trauma day 40 ciliary body cryocoagulation was carried out in 4 spots in the superior cyclodialysis site, as well as at the pre-equatorial retinal level and at the level of the retina l laceration, with 4 further spots under ophthalmoscopic control. At the end of the procedure a paracenthesis was carried out, and 0,3 ml pure C2F6 gas was injected in the vitreous chamber through the superior pars plana. After surgery IOP spiked in the RE up to 28 mm Hg for 48 hs, then slowly receded to normal levels within one week. On postop. Day 1 an inferior, transient, exsudative retinal detachment could be observed, that regressed within the first week. Gas tamponade persisted in the eye for 4 weeks, allowing for stable, gravitational tamponade on the superior targeted trauma site. Choroidal thickening also gradually disappeared and full vision was regained within 6 months. Visual acuity, IOP have remained stable for the following 18 months. The lens remained transparent and no vitreoretinal complication was observed along this observation time. A 54 YO male patient developed cyclodialysis cleft after two consecutive, contusive blunt traumas in his RE. After the first trauma emergency suture of a small peripheral corneal wound was carried out (3 nylon 10/0 nylon sutures). As a consequence of the first trauma the eye developed significant anterior chamber as well as vitreous hemorrhage. The second blunt trauma took place 9 days after the first. The second blunt trauma caused worsening of both AC and VC bleeding. 4 days after the second trauma ocular hypotony was documented, with IOP remaining low, between 4 and 5 mm Hg. As the bleeding disappeared one month later from the AC a wide, temporal angle recession from 7 to 12 hs. and an iridodialysis area at 9 hs. could be observed. Reabsorption of VC blood revealed contusive foveal involvement, with vision barely reaching 20/400. Classic signs of ocular hypotony could also be documented with OCT and B-scan US: choroidal thickening, papilledema and radial retinochoroidal folds, with no improvement occurring with medical therapy (topical cycloplegics and systemic steroids) also in this cas e. In the following 6 months the patient underwent 3 subsequent surgeries: – Iris root suture at the iridodialysis site, cryocoagulation of the ciliary body and intravitreal injection of 0,3 ml of SF6 gas (10 weeks after the second trauma). – Phakoemulsification, in the bag IOL implantation, vitrectomy and C2F6 tamponade, supplementary cryocoagulation of the ciliary body. – Pars plana vitrectomy and silicone oil tamponade 2 weeks after previous surgery by persistent hypotony. – Ciliary body suture During follow-up IOP remained at normal levels during silicone oil tamponade (between 10 and 20 mm Hg). However mantaining this tamponade in this severely traumatized eye seems today, after overall 32 months follow-up, inevitabile. Conclusions: Treatment of hypotony related to post-traumatic cyclodialysis clefts is challenging, because of its rare occurrence and the consequent absence of evidence-based treatment guidelines. Each case has to be treated evaluating its unique individual anatomical features, with the principal aim of protecting central vision from the long-term significant consequences of hypotony. The role of anterior segment US is essential in decision making in these cases. Complex cases may well require multiple surgeries and should be treated by experienced surgeons.


CONTACT DETAILS

 

Enrico Bertelli
Bolzano, Italy
Email : enrbertelli@gmail.com
Cell Phone: +393409191017
Work Phone: +390471908605