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GRAND ROUNDS

GRAND ROUNDS. Denise A. John VEI 1/19/2007. Case. HPI: 17 y/o ♀ s/p trauma OD ~ 2 wks earlier awoke in the AM with severe pain &  vision OD. ROS: Headache & nausea x 2 days PMHX: Umbilical hernia. Case. POHX: Trauma OD Hyphema Commotio retinae Hemorrhagic choroidal detachment

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GRAND ROUNDS

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  1. GRAND ROUNDS Denise A. John VEI 1/19/2007

  2. Case • HPI: 17 y/o ♀ s/p trauma OD ~ 2 wks earlier awoke in the AM with severe pain &  vision OD. • ROS: Headache & nausea x 2 days • PMHX: Umbilical hernia

  3. Case • POHX: • Trauma OD • Hyphema • Commotio retinae • Hemorrhagic choroidal detachment • ø Surgery/lasers • FHX: (-) • SHX: ø Tobacco/ETOH • Allergies: NKDA • Meds: PF 1% qid OD; stopped atropine 1% a wk earlier

  4. Case 20/400  NI • VAsc 20/30 • Motility: Full OU 52 • IOPA 16 • Pupils: Moderately dilated & sluggish OD; ø RAPD

  5. Differential Diagnosis • Hyphema • Traumatic iritis • Traumatic glaucoma • Lens-induced • Ghost cell • Trabecular meshwork damage/Angle recession • Steroid response • Closed cyclodialysis cleft

  6. Case • External exam: Unremarkable OU • SLE: • OD: 2+ conjunctival injection; corneal MCE; AC deep & formed with rare cell; multiple iris sphincter tears; lens clear & centered; trace pigmented vitreous cells • OS: Unremarkable • DFE

  7. Summary • Recent history of blunt trauma OD with period of  IOP with the development of a hemorrhagic choroidal detachment, optic disc edema, retinal venous engorgement & macular striae now with  IOP. • What is your diagnosis?

  8. What would you like to do next?

  9. Case • Assessment: • Spontaneous closure of a cyclodialysis cleft with  IOP • Plan: • IOP  to 32 (alphagan/cosopt/diamox) in clinic • Sent home on glaucoma gtts/diamox/PF & atropine • F/u 3 days

  10. Cyclodialysis: Pathophysiology • Blunt trauma: • Axial compression & rapid compensatory equatorial expansion

  11. Cyclodialysis: Pathophysiology • Separation of the longitudinal ciliary muscle fibers from the scleral spur •  Uveal-scleral outflow

  12. Cyclodialysis • Uncommon • Etiology: • Accidental • Blunt ocular trauma • Ocular surgeries involving manipulation of the iris tissue • Intentional • Glaucoma management

  13. Surgical Cyclodialysis • Heine,1905: • Alternative to filtering surgery, esp. in aphakic glaucoma • Unpredictable results • Complications: Hemorrhage, stripping of Descemet’s, corneal damage, tearing of the iris/ciliary body, lens injury & vitreous loss & phthisis

  14. Cyclodialysis: Complications • Hypotony (IOP < 6) • Internal filtration,  aqueous production or both • Often stabilizes in a few weeks • Magnitude of hypotony ø proportional to size of cleft • Variable VA • Transudation of protein-rich fluid into the subretinal space in posterior pole • Statistical association between IOP < 4 & VA< 20/200

  15. Cyclodialysis: Complications • Shallow AC • Induced hyperopia • Cataract • Choroidal effusion • Retinal & choroidal folds • Engorgement & stasis of retinal veins • CME • Optic disc edema

  16. Diagnosis • Clinical • Gonioscopy • Often small < 4 clock hrs • White band (sclera) below the TM • Ultrasound biomicroscopy (UBM) • Resolution  with higher frequencies at the expense of depth of penetration • 50MHz transducer • 50 μm resolution • 5mm penetration • Accurate assessment of location & size

  17. Cyclodialysis: Management • Goal: Reverse hypotony • Indications for treatment: • Hypotonous maculopathy + disc edema • Macular folds • Choroidal detachment • Corneal edema + worsening vision

  18. Cyclodialysis: Medical • 1st line treatment • Duration: 6 wks • Topical long-acting cycloplegic • 1% Atropine • Corticosteroids ø indicated

  19. Cyclodialysis: Laser • Argon laser photocoagulation (Joondeph,HC; 1980) • 400-800mW • 200μm spot size • 0.1-0.2 sec • Transscleral YAG laser cyclophotocoagulation (Brooks et al.; 1991) • 6 J power • 20 applications • 2-3mm behind limbus

  20. Cyclodialysis: Surgical Techniques • Ciliochoroidal diathermy • Direct cyclopexy • Indirect cyclopexy (McCannel retrievable suture) • Iris-base inclusion cyclopexy • Anterior scleral buckle • Vitrectomy/cryotherapy/gas tamponade

  21. Cyclodialysis: Hypotony Management • Aminlari et al , 2004, described the management of 7 pts with a cyclodialysis cleft • Etiology of cyclodialysis cleft • 1 eye: blunt trauma • 5 eyes: s/p ECCE • 1 eye: s/p trabeculotomy • Duration of ocular hypotony (IOP range 0-6mmHg) • 2 pts: 1-2 wks • 3 pts: 3-5 mos • 2 pts: > 1yr • VA pretreatment: Range 20/50-20/100

  22. Cyclodialysis: Hypotony Management • Management • 4/7 eyes: Medical tx (atropine 1% BID-TID) alone • Hypotony reversed within 1 wk • 2 eyes: 2 treatments of argon laser (1 wk apart) due to ø response atropine tid-qid • Hypotony reversed in 4 days • 1 eye: Surgical closure (direct cyclopexy) • Pediatric pt unable to cooperate at slitlamp for laser • Hypotony reversed POD#1 • VA post-treatment: Range 20/20-20/60

  23. Cyclodialysis: Management Algorithm Ormerod et al, 1991

  24. Cyclodialysis: Management • Cyclodialysis cleft may close spontaneously due to… • Inflammatory response • hyphema • Cycloplegia • May occur within first 6 wks • More common in children

  25. Cyclodialysis: Management • Following resolution, a self-limited ocular hypertension is common within the first 2 wks • IOP rarely > 45mmHg • Miotics are contraindicated

  26. Cyclodialysis: Prognosis • Vision often improves after hypotony is corrected (IOP: 6-12mmHg) • Best results with early correction • Vision may improve rapidly or take months • Delay of treatment > 8 wks  the risk of losing 1-3 snellen lines of vision

  27. Back to our patient… • VA 20/60; IOP nrl on f/u appt. • Tapered pred forte; atropine continued; glaucoma gtts/diamox stopped • ~ 2 wks after IOP normalized, recurrence of  IOP (38); VA 20/50+2; glaucoma gtts resumed; PF/atropine stopped • ~ 2 wk f/u IOP normalized; VA 20/25-2; glaucoma gtts continued • Follow-up 3 mos

  28. Take home points… • Cyclodialysis cleft should be considered with  IOP in setting of blunt trauma. • Closed cyclodialysis cleft should be considered with  IOP and a history of blunt trauma (within 6 wks) and  IOPwith signs of hypotony maculopathy &/or choroidal detachment. • Hypotony is the major complication & is responsible for vision loss. • A hypotonous cyclodiaysis cleft without retinopathy does not require treatment. • Goal of treatment is to reverse the hypotony • Medical treatment is the primary form of management for the first 6 wks.

  29. References • Ormerod et al. Management of a hypotonous cyclodialysis cleft. Ophth 1991; 98 (9): 1384-93 • Tran et al. UBM in the diagnosis & management of cyclodialysis cleft. Asian J Ophth, Vol. 4 (3) 2002; 11-15 • Hansen et al. Visualized cyclodialysis: an additional option in glaucoma surgery. Acta Ophth. 1986; 64: 142-45 • Joondeph HC. Management of postoperative & post-traumatic cyclodialysis clefts with argon laser photocoagulation. Ophth Surg. 1980; 11: 186-88 • Brooks et al. Noninvasive closure of a persistent cyclodialysis cleft. Ophth.1996; 103: 1943-45 • Aminlari et al. Medical/surgical/laser management of cyclodialysis cleft. Arch Ophth. 2004; 122; 399-404 • Alward. Color Atlas of Gonioscopy. AAO. 2001 • BCSC. Glaucoma. AAO. 2004-5 • Yanoff. Traumatic Glaucomas. 2nd Ed. 2004 • Allingham et al. Shield’s testbook of glaucoma. Traumatic Glaucomas. 5th Ed. 2005

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