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Dr.HARATHY SELVAN, Dr.Viney Gupta,Dr.Shikha Gupta

Introduction

Cyclodialysis is the disinsertion of meridional/longitudinal fibres of the ciliary body muscle from the scleral spur, creating an aberrant pathway for aqueous drainage resulting in ocular hypotony.1,2  This low intraocular pressure (IOP) can be quite resistant to conservative management and requires surgical intervention when complications such as cataract, disc oedema, hypotonic maculopathy and vision loss ensues. Traditionally, the type of surgery planned for repair of cyclodialysis is primarily dependent on the extent of cleft and the presence of any associated lens or retinal pathologies.2By this review, we intend to appraise the established methods and update the novel techniques in voguefor the evaluation and management of cyclodialysis clefts.

 Diagnosis of cyclodialysis

I.Clinical

Not all cyclodialysis clefts are diagnosed, especially in the setting of a normal IOP. The suspicion of clefts arises when there is low IOP post-trauma or post-surgery, without any obvious contributing factor.

The gold standard for diagnosis of cyclodialysis isby gonioscopy.2 The detachment of the ciliary body band leads to direct visualization of a deep cleft, showcasing the bare sclera. However, this classic appearance is not always straight forward on gonioscopy, due to co-existing hypotony, resultant Descemet folds and hazy media. To circumvent this difficulty, intracameral viscoelastic injection followed by gonioscopy has been followed. Nevertheless, it seldom helps in pre-operative planning. Also, microclefts and oblique clefts can be easily missed by these techniques.

In order to enhance visualization of these clefts pre-operatively, various adjuncts have been suggested. There have been conflicting reports on the use of both miotics and mydriatics to enhance visualization of the cleft. While the former was hypothesized to open up the angle and hence the clefts, the latter, by deepening the anterior chamber (AC) may facilitate identification of the clefts. We had earlier described the technique of ‘dynamic gonioscopy’ in which by asking the patient to look towards the mirror being examined, the cleft opened up like a ‘rising crescent’ exposing its maximum dimensions.3 It could pick up even the low-lying and the latent clefts that were prone to be missed on routine gonioscopy. Another technique to enhance the visibility of the clefts is by ‘retraction gonioscopy’ where the contact goniolens along with a viscous interface is given a gentle traction so as to deepen the AC by retrograde movement of the lens-iris diaphragm.4 However, pilocarpine was used prior to this procedure.  Another clinical clue to recognize cyclodialysis in the setting of normal IOP is the ‘Shah test’.5 The appearance of corneal folds and hypotony post-gonioscopy due to the sudden hypotony caused by transient shunting of aqueous into the cleft is the basis of this test.

II.Imaging

Ultrasound bio-microscopy (UBM)is an immersion ultrasound technique (35-100 MHz) by which cyclodialysis clefts can be diagnosed even in hypotonus globes, and hence are better meansto diagnosecyclodialysis than gonioscopy.6 Detachment of the ciliary body from the ocular coats and supraciliary drainage pathway can be visualized and measured objectively. The sensitivity can be further enhanced by ‘dynamic UBM’ where the patient is asked to look opposite to the suspected quadrant, opening up a low-lying left.3 It is complimentary to gonioscopy and aids in unravelling the true number and maximum dimensions of the clefts.

Anterior segment optical coherence tomography (ASOCT) is a more recent non-contact, high resolution technique that also helps visualize cyclodialysis clefts.7 Magnetic resonance imaging  (MRI) and scleral transillumination detection are other rare methods for identification of clefts.2

 

Management of cyclodialysis

Many cyclodialysis clefts seal by themselves due to the associated inflammation and cycloplegia obtained. The residual ones require treatment when associated with complications such as cataract, shallow, AC, hypotonic maculopathy, disc edema, permanent retinal damage and deteriorating vision. Cyclodialysis clefts are known for their refractoriness to treatment. Conservative management is always the first option, on failure of which further interventions are attempted. The treatment options have been summarised in table-1.

I.Medical management

Cycloplegics form the mainstay of treatment which on relaxation of the ciliary muscles leads to uveo-scleral approximation.8 Though steroids have been prescribed to raise the IOP and reduce the choroidal effusion, the fact that they would hamper the inflammatory healing should be strongly considered, andhence a rapid tapering of steroids has been recommended.2,8,9 This self-healing may take up to 6-8 weeks duration and this effect is more pronounced in small clefts.

II.Laser photocoagulation

Ab-interno:

a.Argon laser photocoagulation

Argon laser photocoagulation has been considered an easy and safe procedure for closure of small cyclodialysis clefts, especially those less than 1.5 clock hours.10,11 In this technique, laser burns are applied within the cleft site under direct visualization using a goniolens. In situations of very shallow AC, pilocarpine and viscoelastic maybe used to deepen the chamber and provide accurate localization of the cleft. Ormerod et al recommended this technique to serve as the primary treatment approach for closing cyclodialysis clefts.8

b.Diode endophotocoagulation

This 20-gauge endophotocoagulation probe consists of a diode laser source coupled with illuminator and endoscopic camera for direct visualization and treatment of the desired area simultaneously. Both the inner scleral lip and the detached ciliary body face inside the cleft were lasered, and led to increase in IOP within 3-weeks of treatment.12

Ab-externo:

a.Transscleral diode laser

Usually two rows of laser burns with settings of 1500Mw and 1500ms are applied directly over the cleft site. In addition to creation of local inflammation, it also ablates the ciliary processes, thereby evading the post-laser IOP spike. Moro et al recommend this technique to be the best for treatment of small-medium sized clefts resistant to medical management.2

b.Transscleral Nd-YAG laser

Brooks et al described this technique wherein two rows of ten spots per quadrant, each 2-3 mm behind the limbus with a power of 6J were applied via a non-contact system.13 However, this high power delivery to the overlying sclera raises concern.

III.Transscleral diathermy

After raising a partial thickness scleral flap over the area of the cleft, diathermy is applied so as to induce local inflammation.14 However, it fell out of practice due to the risk of scleral ectasia and lens damage induced.

IV.Cryotherapy

It is a transconjunctival technique where the retinal probe (2.8mm diameter) is placed over the site of the cleft and overlapping applications of 5 per quadrant, 30 seconds duration and temperature of -85°C was used.1,15 It is safe and has been combined with surgical procedures also to enhance the success rates by inducing local inflammation.

V.Surgical management

Various methods have been explained in the literature for surgical management of cyclodialysis. We put forward a comprehensive classification of the available surgical options based on the technique followed and mechanism of action involved (summarised in table-1).

Cyclopexy

a.Exocyclopexy (External suture fixation)

Cyclopexyis the procedure of fixation of cyclodialysis clefts. Traditionally, it has been classified into two types, the direct and indirect cyclopexy. ‘Direct cyclopexy’ is the technique in which the ciliary cleft is explored ab-externo and the detached ciliary body is sutured onto the scleral wall under direct visualization. It has been considered as thedefinitive treatment approach for cases that have failed conservative management. They can be done by either fashioningfull thickness scleral flaps (Mackensen and Corydon technique)16 or a partial thickness sclera flap followed by fill-thickness scleral cut-down (Naumann technique).17Other few modifications include intra-operative direct gonioscopy guided18 and probeguided19 identification of clefts followed by repair. and One of the earliest series by Kuchle et al reported closure of clefts in 28 of 29 eyes operated.17Ioannidis et al later reported a success rate of 50% after one procedure, and suggested that larger clefts may require more than one interventions.20Agrawal et al reported combined successof cryopexy and direct cyclopexy to be 94%.21All these techniques employ trans-scleral sutures and are fraught with complications such as haemorrhage, intra-operative hypotony, incomplete suture passes, cataract, retinal detachment, vitreous loss, wound dehiscence, conjunctival bleb formation and endophthalmitis.2 It requires profound surgical expertise and experience for optimal success outcomes.

Usage of trans-corneal sutures to pass radially through the limbus, iris root and the detached ciliary body, to be tied over the scleral surface is known as ‘indirect cyclopexy’,22 a modification of the McCannel retrievable suture technique described for anterior uveal problems.23 Though they were safer, pupillary peaking, angle deformation and peripheral anterior synechiae were a possibility. Though transient IOP spikes have been documented after cleft closure, these permanent angle changes may contribute to secondary glaucoma. Feiler et al modified this technique to pass the sutures only through the sclera, starting 3.5mm posterior to limbus, involving the detached ciliary body and passing out through the sclera 1.5mm behind the limbus.24 Though this appears to spare the pupil and the angle, this is a blind technique and needle exit strictly at the marked position would be tedious.

In addition, the cyclopexy procedures require multiple suture passes along the entire circumference of the cleft, and hence would exponentially increase the chances of short-term and long-term suture-related complications. Such a procedure would be demanding in cases of large cyclodialysis clefts.

b.Endocyclopexy (Internal suture fixation)

These techniques approach the cleft in an inside-out manner. Wang et al described the technique of ‘internal direct cyclopexy’.25 In this technique, routine transconjunctival pars plana ports were made, and lensectomy and limited anterior vitrectomy done. Then a 10-0 polypropylene suture was passed from the pars-plana port opposite to the cyclodialysis, and guided by a 30-gauge (G) needle, the suture was retracted through the sclera overlying the cleft. This was repeated with the other end of the polypropylene needle and then both the ends tied over the sclera to obliterate the cleft. This was followed by completion vitrectomy and addressing of associated retinal problems if present. The mean number of sutures required were 4.6±1.9 (range: 2-9) with an average of average 1.2 per clock hour.

We recently introduced the ‘modified sewing machine technique’ that could correct even large cyclodialysis with a single-suture and single-knot. In this technique, after lifting a partial thickness scleral flap over the affected area, a 9-0 polypropylene suture threaded on a 26G needle is inserted from opposite clear corneal incision to pierce through the detached ciliary body and exit through the scleral bed.  The suture thread is pulled over the scleral bed to form a loop. Securing the loop, the needle is withdrawn and re-inserted at an adjacent site to re-form a loop. This is repeated in a continuous manner along the entire circumference of the cleft. After the final loop, the second end of the suture is retrieved, passed through all the previous loops, titrated and tied with the first end, thereby making it a single-suture, single-knot technique. Another technique to correct both iridodialysis and cyclodialysis in a single instance is the ‘single point pivot technique’ where a single polypropylene suture is looped through the detached iris root and the ciliary cleft to be tied onto the overlying scleral bed, thus anchoring both the tissues simultaneously on the same point of the sclera.

Cyclotamponade

a.Exocyclotamponade

Anterior scleral buckling with silicone tubes and sponges have been described to provide an outside-intamponading effect to the detached ciliary body.26,27 However, they may result in significant astigmatism, foreign body sensation, dellenand cosmetic disfiguration, and therefore,they warrant removal after successful closure of the cleft.1,28

b.Endocyclotamponade

This technique acts on the principle of providing an inside-out mechanical tamponade to the detached ciliary body by the ‘internal cerclage effect’. There are few reports of successful closure of cyclodialysis clefts by providing such Endocyclotamponade by means of appropriate alignment of the haptics of a sulcus intraocular lens (IOL) or a capsular tension ring or a Cionni ring with the eyelet abutting the area of maximum detachment.29–31We had also reported the closure of a cyclodialysis cleft by dual endotamponade technique using both a 3-piece IOL and Cionni ring in the sulcus.32 In addition to the internal compression effect, they also induce inflammation which helps in sealing of the cleft. They are minimally invasive, safe and effective as compared to the external cyclopexy procedures. However, the risks of ciliary body damage, erosion, pain and haemorrhage do remain. The main limitation of this technique is the risk of failure when associated zonular dialysis exists, a frequent accompaniment in post-traumatic scenario. In such situations, due to inadequate sulcus support, the IOL or rings may tilt, providing insufficient cyclotamponade. Also, when combined with cataract surgery, the IOL power calculation should be based on the fellow eye to avoid post-operative refractive surprise.

‘Pneumocyclopexy’ is the technique of using cases to provide endocyclotamponade. Reports of successful repair of large resistant clefts by combination of transconjunctival cryotherapy and intravitreal injection of a single bubble of 20% SF6 and 16% C2F6 gas with appropriate post-operative positioning are known.33,34 However,  these are possible only if the posterior capsule is intact, else the gas in the anterior segment may escape through the cleft and resist its closure.1Pars plana vitrectomy followed by gas/ oil tamponade has also been proposed as an effective technique.35,36They may be combined with cataract surgery in that, vitrectomy and endotamponading agents may themselves accelerate cataract formation, and augmentation with cryotherapy is a viable option to improve success outcomes.37

Our experience

We summarise our experience of treating five eyes with extensive post-traumatic cyclodialysis and ocular hypotony refractory to conservative management. All eyes had coexisting post-traumatic cataract and underwent cataract extraction followed by internal cyclopexy (summarised in table-2). Two eyes underwent in-the-bag IOL and a sulcus Cionni ring ‘endotamponade’. The third eye was treated with ‘dual endotamponade’ of Cionni ring and multipiece IOL in the sulcus with eyelet and haptics aligned along the cleft.32 The forth eye had concurrent zonular dialysis and iridodialysis and was treated with in-the-bag capsular tension ring and IOL with haptic orientated along the zonular defect, CTR in the sulcus for cleft repair followed by ‘stroke and dock’ iridodialysis repair. The fifth eye having iridodialysis and cyclodialysis were both repaired simultaneously by the ‘single point pivot technique’. The fourth eye had failed & was re-operated by ‘modified sewing machine endocyclopexy technique’. Hence, 4/5 eyes showed post-op betterment in IOP and vision after the primary internal cyclopexy, offering a success rate of 80%. The one eye that failed was due to Cionni ring tilting due to inadequate sulcus support secondary to co-existing zonular dialysis. This eye was re-operated by an endocyclopexy technique, which succeeded, collectively offering 100% success rates for the internal cyclopexy methods. They also hold the advantage of being a closed globe technique, repair under direct gionioscopic visualization, possibility of treating concurrent pathologies like cataract and iridodialysis, treating almost entire circumference of the eye, and with an easier learning curve letting any anterior segment surgeon to proceed with.

Ormerod et al had put forward an algorithm of management for cyclodialysis clefts based on the extent of clock hours involved.8 Martin-Moro et al updated the algorithm to include the newer techniques and proposed the management decision based on associated ocular pathologies.2Though all our cases had associated anterior segment abnormalities, nevertheless, we propose that ab-interno techniques such as endocyclotamponade and endocyclopexyin general offer high success rates and maybe considered a viable alternative to the standard external cyclopexy techniques. However, they are preferable only in pseudophakic or aphakic eyes in view of the possible lens injury that can happen. The literature awaitslarge numbered long-term studies summarising the efficacy and safety outcomes of these ab-interno techniques.

In conclusion, cyclodialysis clefts associated with complications require active treatment. Conservative management with mydriatics and cycloplegics always forms the first-line. Failure of medical therapy can be followed by semi-conservative techniques such as the laser and cryocyclopexy. Further more are the interventional surgeries which we have classified based on the methodology and mechanism of action. The ab-interno techniques in general offer high success rates with better safety outcomes, and maybe considered a viable choice to the standard external cyclopexy techniques.

References

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  3. Gupta S, Selvan H, Agrawal S, Gupta V. Dynamic gonioscopy and ultrasound biomicroscopy for diagnosis of latent or low-lying cyclodialysis clefts. Clin Experiment Ophthalmol. 2018 May 7;
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  26. Inukai A, Tanaka S, Hirose A, Tomimitsu S, Mochizuki M. [Three cases of hypotonic maculopathy due to blunt trauma, treated by 360-degree scleral buckling]. Nippon Ganka Gakkai Zasshi. 2003 Jun;107(6):337–42.
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  30. Mardelli PG. Closure of persistent cyclodialysis cleft using the haptics of the intraocular lens. Am J Ophthalmol. 2006 Oct;142(4):676–8.
  31. Malandrini A, Balestrazzi A, Martone G, Tosi GM, Caporossi A. Diagnosis and management of traumatic cyclodialysis cleft. J Cataract Refract Surg. 2008 Jul;34(7):1213–6.
  32. Gupta S, Sagar P, Gogia V, Khokhar S, Dada T. Dual Endotemponade for Extensive Long-standing Cyclodialysis Using Sulcus-fixated Cionni Ring and PCIOL. J Glaucoma. 2016 Mar;25(3):e284-287.
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  34. Pinheiro-Costa J, Melo AB, Carneiro ÂM, Falcão-Reis F. Cyclodialysis Cleft Treatment Using a Minimally Invasive Technique. Case Rep Ophthalmol. 2015 Feb 17;6(1):66–70.
  35. Takaya K, Suzuki Y, Nakazawa M. Four cases of hypotony maculopathy caused by traumatic cyclodialysis and treated by vitrectomy, cryotherapy, and gas tamponade. Graefes Arch Clin Exp Ophthalmol Albrecht Von Graefes Arch Klin Exp Ophthalmol. 2006 Jul;244(7):855–8.
  36. Medeiros MD, Postorino M, Pallás C, Salinas C, Mateo C, Garcia-Arumí J, et al. Cyclodialysis induced persistent hypotony: surgical management with vitrectomy and endotamponade. Retina Phila Pa. 2013 Sep;33(8):1540–6.
  37. Gross JB, Davis GH, Bell NP, Feldman RM, Blieden LS. Surgical repair of large cyclodialysis clefts. Eur J Ophthalmol. 2017 May 11;27(3):382–5.

 

Legends to tables

Table 1: Summary of treatment options available for cyclodialysis.

Table 2: Series of cyclodialysis eyes treated with various ab-interno techniques.

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