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Management of cyclodialysis cleft with transscleral cryotherapy
Manejo de la hendidura de ciclodiálisis con crioterapia transescleral
F. Castillo Capponi
, P. Romera Romero, L. Broc Iturralde, J. Loscos Arenas
Corresponding author
Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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Castillo Capponi, P. Romera Romero, L. Broc Iturralde, J. Loscos Arenas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Castillo Capponi" "email" => array:1 [ 0 => "franciscocastillocapponi@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Romera Romero" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Broc Iturralde" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Loscos Arenas" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo de la hendidura de ciclodiálisis con crioterapia transescleral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 865 "Ancho" => 1583 "Tamanyo" => 131174 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Trans-scleral cryotherapy making two rows of 4 impacts 2 mm form the limbus in the affected area, 4–6 s in duration, until deep whitening was seen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">A cyclodialysis cleft is a rare disease that is produced as a result of a separation of the longitudinal fibers of the ciliary body muscle from the scleral spur, creating a new abnormal way of aqueous humor drainage into the suprachoroidal space.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition to a decreased aqueous humor production caused by a reduced ciliary body perfusion, this disease may lead to an ocular hypotony.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We report a case of cyclodialysis cleft after cataract extraction with intraocular lens implantation followed by hypotony maculopathy. After an unsuccessful conservative treatment, a transscleral cryotherapy was performed achieving closure of the cleft and resolution of the hypotony maculopathy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 74-years-old female patient presented to the ophthalmological consultations with ocular hypotony in her right eye originated after trauma with side instrument during cataract surgery 2 months ago. Right eye best corrected visual acuity (BCVA) was 20/40, with a centered intraocular lens, low grade anterior chamber flare, intraocular pressure (IOP) of 1 mmHg. Also, macular folds, normal optic nerve appearance and no choroidal detachment was seen in the posterior segment. Gonioscopy showed a cyclodialysis cleft at 11 h (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and the anterior segment optical coherence tomography (AS-OCT) showed annular anterior choroidal detachment and a direct communication between anterior chamber and suprachoroidal space at 11 h (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After 1 month of medical treatment with topical dexamethasone and cyclopentolate twice daily with no successful results, the patient subsequently underwent two session of argon laser photocoagulation in the affected area, without any anatomical or clinical improvement. Two weeks later, after a correct surgically visualization of the cleft area with gonioscopy and viscoelastic, we performed a transscleral cryotherapy, making two rows of 4 impacts 2 mm from the limbus in the affected area, 4−6 s in duration, until deep whitening was seen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Twenty four hours later, IOP was 34 mmHg with severe pain and was controlled with topical timolol 0.5% 1 drop twice a day and acetazolamide 250 mg every 8 h. Three months later, BCVA was 20/20, IOP was 10 mmHg without medication, no macular folds were seen, and gonioscopy showed closure of the cyclodialysis cleft and AS-OCT showed resolution of the anterior choroidal detachment (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cyclodialysis can occurs after any blunt trauma (between 1 and 11% and up to 5 joules of energy) or any intraocular surgery with iris manipulation,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> being more common in males than in females. Reports of cyclodialysis after cataract extraction have been published, either in phacoemulsification or extracapsular extraction, trabeculectomy, goniotomy, iridectomy and Kahook dual blade trabeculotomy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Accurate identification and timely intervention of the clef is mandatory as ocular hypotony, defined as IOP below 6 mmHg, can lead to cataract development, optic disc swelling, refractive changes and hypotony maculopathy, producing a misalignment of retinal photoreceptors.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> When hypotony occurs after surgery in the absence of a wound leak, a cleft should be suspected. Classically, gonioscopy has been considered the gold standard for the diagnosis of cyclodialysis, also the use of pilocarpine or viscoelastic can facilitate cleft detection. The most sensitive test for diagnosis is ultrasound biomicroscopy,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but AS-OCT can be also useful for the diagnosis and extension and is a noninvasive, painless, noncontact technique that provides reproducible images of anterior segment.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Even small clefts can lead to severe hypotony due to annular dispersion of fluid to the suprachoroidal space.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Many medical or surgical treatments have been described for cyclodialysis. Medical treatments are used in small clefts and include systemic steroids, topical steroids and cycloplegic drugs, producing a ciliary body rotation facilitating scleral contact.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Surgical treatment should be considered only if hypotony is associated with morphological and functional complications,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> or when hypotony lasts for more than 6 weeks. It includes several techniques, all useful and difficult to compare due to small number of patients treated for each procedure. Argon laser cleft photocoagulation, transscleral YAG laser, transscleral diode laser, transscleral cryotherapy, cyclochoroidal diathermy, direct cyclopexy with prolene sutures, scleral buckling, pneumocyclopexy, vitrectomy with gas endotaponade and intraocular lens implantation in sulcus or Cionni’s ring implantation, have been suggested as treatment for cyclodialysis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6,7,8</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We report a successful cleft resolution with transscleral cryotherapy. Agarwall et al. (2013)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> report 35% success rate with cryotherapy and 100% success rate with direct cycloplexy. Both groups reported postoperative IOP spikes. We first approached this case with cryotherapy as it is easy to perform and less invasive procedure and also considering that cleft length was just one clock hour.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Frequently, the closure of the cleft is followed by a painful IOP spike, as observed in our patient. This spike is a result of the restoration of aqueous humor production by the ciliary body with an incomplete recovery of the trabecular meshwork function.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Any closure technique could potentially cause it.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Cyclodialysis with resultant hypotony can occurs as a complication of many ocular procedures and traumas. Although it is an uncommon complication, it is important to suspect this pathology in postsurgical hypotony and give proper treatment to the patient. We consider that a stepwise approach is the best course of action to treat these patients, starting with medical therapy and continuing with more invasive surgical options.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1674472" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1485683" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1674471" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1485682" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-11-10" "fechaAceptado" => "2021-01-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1485683" "palabras" => array:4 [ 0 => "Cyclodialysis" 1 => "Ocular trauma" 2 => "Ocular hypotony" 3 => "Hypotony maculopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1485682" "palabras" => array:4 [ 0 => "Ciclodiálisis" 1 => "Traumatismo ocular" 2 => "Hipotonía ocular" 3 => "Maculopatía hipotónica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A cyclodialysis cleft is a rare disease that is produced as a result of a separation of the longitudinal fibers of the ciliary body muscle from the scleral spur. A stepwise approach is the best course of action to treat cyclodialysis, starting with medical therapy and continuing with more invasive surgical options. We report a case of ocular hypotony due a traumatic cyclodialysis successfully resolved with transscleral cryotherapy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La hendidura de ciclodiálisis es una enfermedad rara que se produce como resultado de una separación de las fibras longitudinales del músculo del cuerpo ciliar del espolón escleral. La mejor forma de tratar la ciclodiálisis es por etapas, comenzando con una terapia médica y continuando con opciones quirúrgicas más invasivas. Presentamos un caso de hipotonía ocular debida a una ciclodiálisis traumática que se resolvió con éxito mediante crioterapia transescleral.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Castillo Capponi F, Romera Romero P, Broc Iturralde L, Loscos Arenas J. Manejo de la hendidura de ciclodiálisis con crioterapia transescleral. Arch Soc Esp Oftalmol. 2022;97:165–167.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1217 "Ancho" => 2917 "Tamanyo" => 510926 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">At diagnosis: (a) Anterior segment optical coherence tomography (AS-OCT) showing annular anterior choroidal detachment (red arrows). (b) Direct communication between anterior chamber and suprachoroidal space at 11 h (yellow arrow). (c) Posterior segment macular folds. (d) Gonioscopy showing cyclodialysis cleft at 11 h (red arrow).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 865 "Ancho" => 1583 "Tamanyo" => 131174 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Trans-scleral cryotherapy making two rows of 4 impacts 2 mm form the limbus in the affected area, 4–6 s in duration, until deep whitening was seen.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 851 "Ancho" => 1583 "Tamanyo" => 217877 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Three months after trans-scleral cryotherapy (a) No macular folds in the posterior segment. 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