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Ultrasonic Biomicroscopic Evaluation of Cyclodialysis Before and After Direct Cyclopexy
Jeong-Min Hwang, MD;
Kyeon Ahn, MD;
Chihoon Kim, MD;
Kyung-Ah Park, MD;
Changwon Kee, MD
Arch Ophthalmol. 2008;126(9):1222-1225.
ABSTRACT
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Objectives To investigate the clinical manifestations and surgical prognoses after direct cyclopexy in patients with traumatic cyclodialysis according to the cleft extent as determined by ultrasound biomicroscopy (UBM).
Methods A detailed ophthalmologic examination, which included gonioscopy and UBM, was performed before and after direct cyclopexy in 32 eyes of 31 patients with traumatic cyclodialysis clefts.
Results Cyclodialysis clefts were accurately diagnosed and delineated in all 32 eyes using UBM. Cyclodialysis resulted in hypotony with a mean intraocular pressure of 3.2 mm Hg irrespective of cleft size. On A-scan ultrasonography, mean (SD) preoperative and postoperative lens thicknesses were 4.4 (0.4) mm (range, 3.71-4.92 mm) and 4.1 (0.4) mm (range, 3.42-4.57 mm), respectively, and mean (SD) preoperative and postoperative axial lengths were 23.2 (0.7) mm (range, 21.91-24.57 mm) and 23.6 (0.7) mm (range, 22.47-24.56 mm), respectively. The larger a cleft was, the longer it took for a postoperatively elevated intraocular pressure to normalize after direct cyclopexy. Postoperative visual acuities were significantly better than preoperative values, even when direct cyclopexy was performed 54 months after trauma.
Conclusions Even small clefts usually resulted in hypotony and visual prognosis was better after cyclopexy, even in cases with a protracted history. Larger clefts need longer postoperative follow-up to check for intraocular pressure normalization after direct cyclopexy.
INTRODUCTION
Cyclodialysis describes the disinsertion of longitudinal ciliary muscle fibers from the scleral spur, which results in a cleft that communicates between the anterior chamber and the suprachoroidal space.1-16 Because gonioscopy is difficult to perform on a shallow anterior chamber and a soft eye, ultrasound biomicroscopy (UBM) provides the best means for diagnosing cyclodialysis clefts.2-5 However, no UBM-based study has been undertaken to precisely evaluate the extent of cyclodialysis and its clinical manifestations in a large number of patients. In this study, we evaluated the extent of cyclodialysis using UBM and not only analyzed physiologic changes of lens thickness, depth of anterior chamber, and axial length caused by cyclodialysis but also determined surgical prognoses after direct cyclopexy.
METHODS
PATIENT SELECTION
Thirty-two eyes of 31 consecutive patients (24 males, 7 females; 1 eye had bilateral cyclodialysis clefts) who had received a diagnosis of a cyclodialysis cleft and had undergone direct cyclopexy at the Department of Ophthalmology at the Samsung Medical Center between February 1997 and May 2006 were enrolled. Mean patient age was 41.6 (13.3) years (range, 14-63 years) and the mean (SD) follow-up period after cyclopexy was 21.1 (18.3) months. Detailed ophthalmologic examinations included measuring best-corrected visual acuity, intraocular pressure (IOP), and refractive errors; slitlamp biomicroscopy; gonioscopy; funduscopy; A-scan ultrasonography to measure axial length, lens thickness, and anterior chamber depth; and UBM to identify the extent of cyclodialysis cleft (Figure 1).
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Figure 1. Ultrasound biomicroscopy showing cyclodialysis cleft. Iris is lying against the scleral spur with no apparent cleft on gonioscopy. The ciliary body (CB) is detached and supraciliary fluid is observed. S indicates sclera.
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DIRECT CYCLOPEXY
Direct cyclopexy16 was performed as follows: a conjunctival flap was made at the site of the cyclodialysis cleft and the sclera was exposed. A partial-thickness scleral flap was then made 4 mm posterior to the limbus. After elevating the scleral flap, the sclera was incised 1.5 mm posterior and parallel to the limbus. Aqueous humor was released, and the cyclodialysis cleft was visualized. The detached ciliary body was directly fixed to the sclera with an interrupted loop suture through the anterior sclera, the ciliary body, and again through the posterior scleral lip using 10-0 nylon sutures. The scleral flap and conjunctiva were then closed. Postoperatively, cycloplegics and antibiotics were dropped onto eyes. To control temporary IOP increases, a topical β-blocker, an oral carbonic anhydrase inhibitor, or an intravenous hyperosmotic agent was used.
Two months postoperatively, an identical ophthalmologic examination, which included UBM, was performed (Figure 2). The paired t test was used to compare preoperative and postoperative measurements of visual acuity, IOP, spherical equivalent of refractive errors, axial length, anterior chamber depth, and lens thickness.
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Figure 2. Ultrasound biomicroscopy showing closure of cyclodialysis cleft after cyclopexy with reattachment of the ciliary body posterior to the scleral spur and resolution of cyclodialysis cleft. Arrows indicate echoshadows of the 10-0 nylon sutures.
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Correlations between postoperative visual acuity and possible prognostic factors, such as preoperative visual acuity, preoperative IOP, and extent and duration of clefts, were evaluated using Spearman correlation coefficients. Correlations between cleft extent and postoperative IOP and between time to IOP normalization (< 21 mm Hg) postoperatively and extent or duration of cyclodialysis clefts were evaluated using Spearman correlation coefficients. Data are given in mean (SD).
RESULTS
Mean cyclodialysis cleft extent as estimated by UBM was 4.3 (2.5) clock-hours (range, 1-12 clock-hours) (Table). Before cyclopexy, cataracts were found in 17 of the 32 eyes, and cataract surgery was performed on 7 eyes at the time of direct cyclopexy and on 6 eyes later as a second procedure. Three eyes were accompanied by lens subluxation and were treated with lens extraction and scleral fixation of an intraocular lens. On funduscopy, all eyes showed hypotony-induced maculopathy.
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Table. Demographics of Patients With Cyclodialysis Before and After Direct Cyclopexy
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Preoperative corrected visual acuities were 20/40 or better in 7 eyes (22%), worse than 20/40 and better than 20/200 in 11 eyes (34%), and 20/200 in 14 eyes (44%). Final corrected visual acuities were 20/40 or better in 24 eyes (75%) and worse than 20/40 and better than 20/200 in 8 eyes (25%). Of the 8 eyes with final corrected visual acuities worse than 20/40, 3 patients had cataracts that were not operated on, 2 patients had choroidal ruptures, 1 patient had a corneal laceration, 1 patient had preexisting corneal opacity, and 1 patient had an unknown cause for this poor visual acuity. Preoperative and postoperative mean logMAR visual acuities were 1.07 (0.91) logMAR and 0.24 (0.24) logMAR, respectively (P = .002). Postoperative visual acuity was not found to be correlated with cleft duration (P = .61), preoperative IOP (P = .24), preoperative visual acuity (P = .24), or cleft extent (P = .17).
Mean preoperative IOP was 3.2 (2.6) mm Hg (range, 0-10 mm Hg). Two patients with a cleft of 1 clock-hour extent had IOPs of 3 and 0 mm Hg. After cyclopexy, mean IOPs abruptly increased maximally to 36.5 (14.4) mm Hg (range, 12-70 mm Hg) and subsequently decreased to less than 21 mm Hg within a mean of 14.4 (9.2) days (range, 1-30 days) (Figure 3). Time to IOP normalization (< 21 mm Hg) without using an antiglaucoma agent postoperatively was found to be significantly correlated with cleft extent (P = .004) but showed no significant correlation with cleft duration (P = .31) or preoperative IOP (P = .14). Mean preoperative and postoperative spherical equivalents were – 1.53 (2.28) diopters (D) (range, – 7.00 to 2.75 D) and – 0.46 (1.31) D (range, – 3.38 to 2.38 D), respectively.
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Figure 3. Intraocular pressure (IOP) after cyclopexy. Mean IOP abruptly increased maximally to 36.5 (SD, 14.4) mm Hg (range, 12-70 mm Hg) and then decreased to less than 21 mm Hg within a mean of 14.4 (SD, 9.2) days (range, 1-30 days) without an antiglaucoma agent.
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On A-scan ultrasonography, mean preoperative and postoperative anterior chamber depths were 2.40 (0.30) mm (range, 2.00-3.00 mm) and 3.40 (0.30) mm (range, 3.00-4.06 mm), respectively; mean preoperative and postoperative lens thicknesses were 4.4 (0.4) mm (range, 3.71-4.92 mm) and 4.1 (0.4) mm (range, 3.42-4.57), respectively; and mean preoperative and postoperative axial lengths were 23.2 (0.7) mm (range, 21.91-24.57 mm) and 23.6 (0.7) mm (range, 22.47-24.56 mm), respectively (Table). Postoperatively, lens thicknesses significantly decreased (P < .001) and axial lengths significantly increased (P = .007). Cleft extent showed no significant correlation with postoperative IOP (P = .52) or lens thickness changes (P = .73). However, cataract developed in all 6 patients with a cyclodialysis cleft of larger than 6 clock hours. Postoperative posterior synechiae were rarely observed after a direct cyclopexy.
COMMENT
Ultrasound biomicroscopy is a noninvasive method that uses high-frequency (50-60 MHz) transducers to accurately image anterior segment structures17; it is especially useful when it is not possible to perform gonioscopy to validate the presence and extent of a cyclodialysis cleft.2-5 In this study, we successfully evaluated clefts with significant hypotony in all patients. A-scan ultrasonography showed that lens thicknesses increased and that anterior chamber depths and axial lengths decreased in eyes with a cyclodialysis cleft. This increase in lens thickness could have been caused by the inward rotation of the ciliary body owing to the cleft, thereby relaxing the zonule. Reductions in anterior chamber depth may have been caused by excessive aqueous outflow and forward movement of the lens. Axial lengths were probably reduced by overall eyeball retractions owing to hypotony. Moreover, all of these changes were reversible. After reattachment of the ciliary body and IOP normalization, anterior chamber depths and axial lengths significantly increased and lens thicknesses significantly decreased.
Visual acuity may not improve after cleft closure owing to irreversible wrinkling and fibrosis of the retina and choroids.7-8 Therefore, it might be assumed that hypotony maculopathy due to cyclodialysis cleft should be treated as early as possible. In our study, visual acuity improved in 30 eyes and was the same in 2 eyes with preoperative visual acuities of 20/20 and 20/30. The visual acuity of a patient who underwent cyclopexy 1 year after trauma improved from 20/800 to 20/50 and that of another patient who underwent cyclopexy 56 months after trauma improved from 20/400 to 20/70 (Table). This finding indicates that direct cyclopexy is beneficial even in cases of protracted duration. Given the normalization of IOP postoperatively, visual acuity was found to be significantly improved postoperatively. This finding indicates that IOP normalization alleviates complications, such as retinal and choroidal wrinkling, corneal folding, and refractive errors caused by a shallow anterior chamber.
In our analysis of visual prognostic factors, short disease duration was not found to be correlated with good vision. A small number of studies have addressed the correlation between hypotonic duration and visual prognosis in cases with a cyclodialysis cleft. Kato et al12 recommended that direct cyclopexy be performed before irreversible retinal wrinkling occurred owing to persistent hypotony. In contrast, Küchle and Naumann13 found no significant correlation between hypotony duration and postoperative visual acuity prognosis. Similarly, in the present study, no significant correlation was found between visual prognosis and hypotonic duration or between visual prognosis and cleft extent.
Although the mechanism underlying the postoperative increase in IOP has not been clarified, a trabecular meshwork impaired by hypotony probably needs time to recover. However, cleft duration was not found to be significantly correlated with time to IOP normalization postoperatively, which suggests that cyclodialysis clefts do not cause permanent trabecular damage but rather a transient dysfunction of the trabecular meshwork.
In our study, cyclodialysis cleft extent was found to be related to the time required for IOP normalization after direct cyclopexy. Thus, a larger cleft may impair a wider region of the trabecular meshwork and sustain higher postoperative IOP for a longer period. Moreover, a cataract developed in all patients with a cyclodialysis cleft larger than 6 clock-hours, indicating that the development of cataract should be anticipated in such patients.
In conclusion, direct cyclopexy was found to successfully treat hypotonic cyclodialysis clefts. Even small clefts usually resulted in hypotony, and visual prognosis was good even in cases with protracted cleft duration. We recommend that cyclopexy be considered in all cases of traumatic cyclodialysis.
AUTHOR INFORMATION
Correspondence: Changwon Kee, MD, Department of Ophthalmology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea (ckee{at}skku.edu).
Submitted for Publication: December 3, 2007; final revision received March 2, 2008; accepted March 21, 2008.
Financial Disclosure: None reported.
Author Affiliations: Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea (Dr Hwang); and Department of Ophthalmology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea (Drs Ahn, Kim, Park, and Kee).
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