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Traumatic cyclodialysis treated with transscleral ciclodiode laser: Anterior and posterior segment evolution
Ciclodiálisis traumática tratada con láser ciclodiodo transescleral: evolución de la exploración del segmento anterior y posterior
J. González-Martín-Moroa,b,
, M. Castro-Rebolloa, J. Zarallo-Gallardoa,b, F.J. Muñoz-Negretec,d
Corresponding author
a Servicio de Oftalmología, Hospital Universitario del Henares, Madrid, Spain
b Grado de Medicina, Universidad Francisco de Vitoria, Madrid, Spain
c Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain
d Departamento de Cirugía, Universidad de Alcalá de Henares, Alcalá de Henares (Madrid), Spain
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E-H) Retinografía, OCT de segmento posterior, gonioscopia y OCT 3<span class="elsevierStyleHsp" style=""></span>D de segmento anterior un mes tras el tratamiento con láser (6 meses tras el traumatismo). La OCT de segmento anterior fue realizado utilizando un OCT Casia 3D-anterior segment-OCT SS1000® (Tomey, Erlangen, Germany).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. González-Martín-Moro, M. Castro-Rebollo, J. Zarallo-Gallardo, F.J. Muñoz-Negrete" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "González-Martín-Moro" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Castro-Rebollo" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Zarallo-Gallardo" ] 3 => array:2 [ "nombre" => "F.J." 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"apellidos" => "Muñoz-Negrete" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario del Henares, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grado de Medicina, Universidad Francisco de Vitoria, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Cirugía, Universidad de Alcalá de Henares, Alcalá de Henares (Madrid), Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ciclodiálisis traumática tratada con láser ciclodiodo transescleral: evolución de la exploración del segmento anterior y posterior" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2316 "Ancho" => 1500 "Tamanyo" => 409960 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A)–(D) Retinograph, posterior segment OCT gonioscopy and 3-D anterior segment OCT 3 days after traumatism. (E)–(H) Retinograph, posterior segment OCT, gonioscopy and 3-D anterior segment OCT one month after laser treatment (6 months after traumatism). Anterior segment OCT was taken with a Casia 3D-anterior segment-OCT SS1000<span class="elsevierStyleSup">®</span> device (Tomey, Erlangen, Germany).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cyclodialysis occurs due to the separation of the ciliary muscle from the scleral spur. This produces a secondary exit pathway of aqueous humor as well as ocular hypotony.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In the past, surgically induced cyclodialysis was regarded as a therapeutic alternative for patients with glaucoma.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Cyclodialysis could occur as a complication of any anterior segment surgery involving manipulation of the iris or as the result of blunt traumatism.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The present article describes the typical evolution of anterior and posterior segment examination in a patient exhibiting traumatic cyclodialysis treated with diode laser, with a brief discussion of therapeutic options currently available.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinic case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">Male patient, age 35, who visited 3 days after getting a kick in the left eye (LE). VA was finger counting in LE, with 1<span class="elsevierStyleHsp" style=""></span>mm hyphema and IOP of 4<span class="elsevierStyleHsp" style=""></span>mmHg. Ocular fundus examination revealed choroidal rupture and extensive subretinal hemorrhage as well as radial folds in the macular area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The papilla was edematous. 3-D optical coherence tomography (OCT) utilizing a 3D-OCT Topcon 2000 device (Topcon Corporation, Tokyo, Japan) confirmed the presence of edema in the peripapillary nerve fiber layer and hypotension maculopathy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Gonioscopy demonstrated the existence of angle recession area and inferior iridodialysis extending up to 3 o’clock (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). A clear cyclodialysis area could not be identified utilizing anterior segment OCT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D) or ultrasound biomicroscopy (UBM). The OCT device utilizing for studying the anterior segment was Casia 3D-anterior segment-OCT SS1000<span class="elsevierStyleSup">®</span> (Tomey, Erlangen, Germany). Even though the cyclodialysis was not located, diagnostic suspicion was high and therefore corticoid treatment was diminished, initiating treatment with atropine (once a day).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After 5 months, VA and IOP had not improved. Accordingly, laser treatment was resorted to. The utilized device was Oculight SLx (Iris Medical Instruments, Mountain View, CA, USA) equipped with the G probe. Two rows of 20 transscleral diode laser impacts (2<span class="elsevierStyleHsp" style=""></span>W, 3<span class="elsevierStyleHsp" style=""></span>s) were applied over the ciliary body at the inferior 180° behind the estimated location of the ciliary processes. Said extended exposure time (“slow-burn”) produces an enhanced coagulative effect. Three weeks later, hypotony resolved accompanied by a hypertensive peak and the disappearance of the papillary edema and choroidal folds (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E and F). However, VA did not improve due to the presence of the choroidal rupture. Since then, IOP has remained stable between 10 and 14<span class="elsevierStyleHsp" style=""></span>mmHg, and the anterior segment 3D OCT showed a slight reduction of the iridodialysis area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>G and H). Two years later, the patient developed subretinal neovascular membrane over the choroidal rupture, being treated at present with intravitreal endothelial vascular growth factor inhibitors.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cyclodialysis is the result of the separation of the longitudinal portion of the ciliary muscle from the scleral spur, which induces hypotony that alters ocular physiology and leads to the appearance of cataracts, papillary edema, refractive changes and hypotony maculopathy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Conventionally, gonioscopy constitutes the treatment of choice when cyclodialysis is diagnosed. However, this treatment is complex in these patients due to hypotony, the presence of corneal folds and a narrow anterior chamber.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In addition, some cyclodialysis could include uveoscleral hyperfiltration without creating a suprachoroidal space due to the apposition between both surfaces, which significantly hampers the identification of the fistula opening in gonioscopy. In fact, the fistula could not be identified in the present patient. In addition, it can be seen that the quality of the gonioscopy image after closing cyclodialysis and normalizing IOP is much higher.</p><p id="par0030" class="elsevierStylePara elsevierViewall">UBM is probably the best techniques for diagnosing said complication, but in the present patient neither OCT nor UBM enabled the localization of the fistula. Anterior segment 3-D OCT shows the existence of a broad iridodialysis area but without allowing the identification of the cyclodialysis site.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Some small cyclodialysis can be closed with medical treatment.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> However, in many cases surgical treatment is required. The classic technique is direct cyclopexia<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> although in recent years some clinic case reports and small series demonstrated that anterior segment surgical techniques (implantation of intraocular lens or capsular tension ring in the sulcus)<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,7</span></a> as well as posterior segment techniques (vitrectomy, cerclage or gas injection)<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> are able to induce fistula closure. Even so, the authors consider that transscleral diode laser cyclo-photocoagulation is the treatment of choice in small cyclodialysis that are not associated to cataracts or concomitant retinal pathology and remain unresponsive to medical treatment.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Said treatment constitutes a diffuse treatment that can be applied over a broad area without the risks associated to intraocular procedures and with low cost<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> that enables the closure of a small cyclodialysis even without having precise location.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres873577" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec862218" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres873576" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec862219" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-09-19" "fechaAceptado" => "2016-12-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec862218" "palabras" => array:4 [ 0 => "Cyclodialysis" 1 => "Blunt ocular trauma" 2 => "Ocular hypotony" 3 => "Hypotony maculopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec862219" "palabras" => array:4 [ 0 => "Ciclodiálisis" 1 => "Traumatismo ocular contuso" 2 => "Hipotonía ocular" 3 => "Maculopatía por hipotensión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case report</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 35-year-old man suffered a severe hypotension maculopathy after being kicked in his left eye. He presented a broad area of iridodialysis. Gonioscopy, ultrasound biomicroscopy and optic coherence tomography were not able to locate the suspected cyclodialysis. Medical treatment was ineffective. Five months later the patient received transcleral diode laser cyclophotocoagulation with clinical resolution.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transscleral diode laser constitutes an effective treatment, with low iatrogenia, that can solve cases of ocular hypotension, even when the location of the cyclodialysis has not been determined.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Caso clínico</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Paciente varón de 35 años de edad, que presentó un cuadro severo de maculopatía por hipotensión tras recibir una patada en el ojo izquierdo. Presentaba una zona amplia de iridodiálisis. La gonioscopia, biomicroscopia ultrasónica y tomografía de coherencia óptica no permitieron localizar la ciclodiálisis. Cinco meses después, ante la falta de respuesta al tratamiento médico, el paciente fue tratado con ciclofotocoagulación transescleral con láser de diodo, que produjo la resolución del cuadro clínico.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La ciclofotocoagulación transescleral con láser diodo constituye un tratamiento eficaz, produce poca iatrogenia y permite incluso resolver cuadros de hipotensión ocular producidos por ciclodiálisis que no han podido ser localizadas.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Martín-Moro J, Castro-Rebollo M, Zarallo-Gallardo J, Muñoz-Negrete FJ. Ciclodiálisis traumática tratada con láser ciclodiodo transescleral: evolución de la exploración del segmento anterior y posterior. Arch Soc Esp Oftalmol. 2017;92:386–389.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2316 "Ancho" => 1500 "Tamanyo" => 409960 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A)–(D) Retinograph, posterior segment OCT gonioscopy and 3-D anterior segment OCT 3 days after traumatism. (E)–(H) Retinograph, posterior segment OCT, gonioscopy and 3-D anterior segment OCT one month after laser treatment (6 months after traumatism). Anterior segment OCT was taken with a Casia 3D-anterior segment-OCT SS1000<span class="elsevierStyleSup">®</span> device (Tomey, Erlangen, Germany).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cyclodialysis: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Gonzalez-Martin-Moro" 1 => "I. Contreras-Martin" 2 => "F.J. Munoz-Negrete" 3 => "F. Gomez-Sanz" 4 => "J. 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