Indirect cyclopexy for treatment of a chronic traumatic cyclodialysis cleft with hypotony
A 70-year-old Caucasian male followed at the Martinsburg Veterans Affair Hospital Ophthalmology Clinic, Martinsburg, West Virginia, USA, since 2002 was found consistently to have intraocular pressure (IOP) asymmetry, with the right eye IOP ranging from 6–15 mmHg and usually having an IOP 04 mmHg lower than the left eye. He was monitored for primary open-angle glaucoma and was on latanoprost eye drops in the left eye for field defects in that eye. In April 2008, his right eye IOP dropped to 04 mmHg. On further evaluation, gonioscopy revealed a cyclodialysis cleft from 11–4 o’clock. The patient’s history was significant for trauma to the right eye with a piece of wood over 30 years ago, which was thought to be the cause of the cleft.\nWhile the patient had hypotony, he maintained good visual acuity, ranging from 20/25 to 20/40, and was therefore observed for approximately 3 years until December 2011. At this visit, his visual acuity dropped to 20/150 and he clinically developed Descemet’s folds with a shallow anterior chamber and an IOP of 02 mmHg. On dilated fundus exam, he had a shallow choroidal hemorrhage and effusion in the far nasal periphery. The patient was initially treated medically with atropine and prednisolone acetate 1% ophthalmic drops for approximately 2 months, without improvement in IOP and with persistence of choroidal hemorrhage and effusion. Vision also remained poor. Given the chronicity and size of this cyclodialysis cleft, surgical repair was planned.\nAn indirect method of closure was performed and the technique is described below. Postoperatively, the choroidal effusion resolved, but the patient’s IOP did not improve. On repeat gonioscopy, it was determined that there were 2 clock hours of remaining cleft. Therefore, the patient was taken for additional surgical repair of the persistent cleft by the same technique, this time with successful closure.\nOn postoperative day 1 following the second surgery, the patient complained of severe eye pain and nausea, and was found to have an lOP of 58 mmHg. Elevated intraocular pressure was anticipated with successful closure of cyclodialysis cleft. The patient was treated with topical anti-glaucoma drops and oral acetazolamide, with reduction in the IOP to the mid-teens and resolution of his pain. On exam, there was no distortion of the pupil by sutures and the anterior chamber appeared deep (). Repeat gonioscopy also confirmed cleft closure (). The patient was subsequently tapered off the oral acetazolamide and topical drops, with stabilization of the pressure in the mid-teens and maintenance of 20/70 visual acuity at 1 year postoperatively. Final visual acuity was limited by subsequent progression of ocular comorbidities in that eye, including cataract and proliferative diabetic retinopathy.\nA nasal conjunctival peritomy was performed, and dissection down to bare sclera was carried out and continued superotemporally to encompass the region of the cyclodialysis cleft. A 10-0 nylon suture on CS175-6 needle (Ethicon), which is a 7.0 mm ½-circle needle, was selected for cyclopexy. Interrupted 10-0 nylon sutures were radially passed through the corneal side of the limbus, then through the iris root and ciliary body, and carried out through the sclera on the opposite side of the limbus (). To ensure that ciliary body was incorporated into each pass, the sutures were tugged on intraoperatively and the iris root was evaluated for movement with mechanical pull. Additionally, as more sutures were placed, the eye appeared to become more firm. The sutures were placed approximately 1 mm apart. We found the needle type to have a curvature and size that was very helpful for the angle and length of the pass required.