cyclodialysis cleft is a rare clinical finding , but one that can have significant ocular complications , including decreased vision , shallowing of the anterior chamber , corneal edema , hypotony , choroidal effusions , maculopathy , vascular tortuosity , and optic disc edema .
while it can be caused by surgical manipulation of the eye , it is more frequently a consequence of trauma.1 traumatic injury to the eye results in separation of the ciliary body from the scleral spur , which creates an aberrant outflow pathway for aqueous humor through the suprachoroidal space and often leads to hypotony .
cyclodialysis cleft has been reported to occur in 3.4% of cases of ocular injury or globe rupture.2 additionally , one large review of 291 cases involving cyclodialysis suggested that hypotony occurs 9% of the time.3 medical treatment with atropine ophthalmic drops and laser therapy to promote reattachment of the ciliary body to the scleral spur are options for repair of this entity , but larger and more chronic cyclodialyses often require surgical repair.4,5 because of their rarity , reports on surgical repair techniques in the literature are limited .
we share a novel , simple surgical approach to management of a case of chronic traumatic cyclodialysis cleft with a successful outcome .
a 70-year - old caucasian male followed at the martinsburg veterans affair hospital ophthalmology clinic , martinsburg , west virginia , usa , since 2002 was found consistently to have intraocular pressure ( iop ) asymmetry , with the right eye iop ranging from 615 mmhg and usually having an iop 04 mmhg lower than the left eye .
he was monitored for primary open - angle glaucoma and was on latanoprost eye drops in the left eye for field defects in that eye . in april 2008 ,
the patient s history was significant for trauma to the right eye with a piece of wood over 30 years ago , which was thought to be the cause of the cleft .
while the patient had hypotony , he maintained good visual acuity , ranging from 20/25 to 20/40 , and was therefore observed for approximately 3 years until december 2011 . at this visit ,
his visual acuity dropped to 20/150 and he clinically developed descemet s folds with a shallow anterior chamber and an iop of 02 mmhg .
on dilated fundus exam , he had a shallow choroidal hemorrhage and effusion in the far nasal periphery .
the patient was initially treated medically with atropine and prednisolone acetate 1% ophthalmic drops for approximately 2 months , without improvement in iop and with persistence of choroidal hemorrhage and effusion .
postoperatively , the choroidal effusion resolved , but the patient s iop did not improve . on repeat gonioscopy
therefore , the patient was taken for additional surgical repair of the persistent cleft by the same technique , this time with successful closure .
on postoperative day 1 following the second surgery , the patient complained of severe eye pain and nausea , and was found to have an lop of 58 mmhg .
the patient was treated with topical anti - glaucoma drops and oral acetazolamide , with reduction in the iop to the mid - teens and resolution of his pain . on exam
, there was no distortion of the pupil by sutures and the anterior chamber appeared deep ( figure 1 ) .
the patient was subsequently tapered off the oral acetazolamide and topical drops , with stabilization of the pressure in the mid - teens and maintenance of 20/70 visual acuity at 1 year postoperatively .
final visual acuity was limited by subsequent progression of ocular comorbidities in that eye , including cataract and proliferative diabetic retinopathy .
a nasal conjunctival peritomy was performed , and dissection down to bare sclera was carried out and continued superotemporally to encompass the region of the cyclodialysis cleft .
a 10 - 0 nylon suture on cs175 - 6 needle ( ethicon ) , which is a 7.0 mm -circle needle , was selected for cyclopexy .
interrupted 10 - 0 nylon sutures were radially passed through the corneal side of the limbus , then through the iris root and ciliary body , and carried out through the sclera on the opposite side of the limbus ( figure 3 ) . to ensure that ciliary body was incorporated into each pass ,
the sutures were tugged on intraoperatively and the iris root was evaluated for movement with mechanical pull
. additionally , as more sutures were placed , the eye appeared to become more firm .
we found the needle type to have a curvature and size that was very helpful for the angle and length of the pass required .
a nasal conjunctival peritomy was performed , and dissection down to bare sclera was carried out and continued superotemporally to encompass the region of the cyclodialysis cleft .
a 10 - 0 nylon suture on cs175 - 6 needle ( ethicon ) , which is a 7.0 mm -circle needle , was selected for cyclopexy .
interrupted 10 - 0 nylon sutures were radially passed through the corneal side of the limbus , then through the iris root and ciliary body , and carried out through the sclera on the opposite side of the limbus ( figure 3 ) . to ensure that ciliary body was incorporated into each pass ,
the sutures were tugged on intraoperatively and the iris root was evaluated for movement with mechanical pull .
additionally , as more sutures were placed , the eye appeared to become more firm .
we found the needle type to have a curvature and size that was very helpful for the angle and length of the pass required .
multiple approaches to cleft closure have been described in the literature , including medical management , laser photocoagulation , cryotherapy , trans - scleral diathermy , gas tamponade , and anterior scleral buckle , along with various surgical repair techniques.6 while different surgical approaches have been described , many are technically challenging , particularly in the hypotonous eye . in this case report
, we discuss the repair of a chronic traumatic cyclodialysis with indirect surgical cyclopexy , which we found to be technically easier and less invasive than other reported techniques , but equally successful .
compared to the direct cyclopexy described in a review by ioannidis and barton,6 our indirect technique eliminated the need for direct visualization of the ciliary body , thereby reducing technical difficulty along with bleeding and wound dehiscence risk . additionally , compared to cyclopexy described by mccannel,7 our approach eliminated the additional need for clear corneal stab incision with retrieval of suture , which can also be difficult in a soft , hypotonous eye and may prolong surgical time . while our technique was successful , it required two operations to achieve successful cleft closure with improvement in iop .
our first attempt failed , likely due to the spacing of our sutures in one particular quadrant , which we determined were too far apart .
additionally , we used a needle with less curvature and length initially . we found that spacing the sutures approximately 1 mm apart achieved good apposition of ciliary body to scleral spur and , ultimately , closure of the cleft with restoration of physiologic iop .
the length and curvature of the cs175 - 6 ( ethicon , cincinnati , ohio , usa ) needle also assisted with passage of each suture through the targeted tissues .
the patient s postoperative iop spike after the second surgery was suggestive of successful closure of the cleft.1 additionally , successful closure was later confirmed by gonioscopy .
another challenge to our case was the chronicity of the injury which was sustained 30 years prior to presentation as per the patient s self - reported history .
there was concern that , even with successful anatomic closure , iop and visual function may not be restored due to chronic ischemic changes to the ciliary body . however , our repair achieved both anatomic and functional success , suggesting that even chronic cyclodialysis clefts can be effectively repaired .
delgado et al reported a similar finding in a case of hypotony maculopathy secondary to cyclodialysis that was resolved with cleft closure 7 years later.8 cyclodialysis is a vision - threatening ocular injury that can often be difficult to treat medically .
surgical repair is often necessary but can be technically difficult and challenging , particularly because of how rarely it is encountered in clinical practice .
we present a simple , less - invasive approach to surgical cleft closure that was successful anatomically and functionally .
additionally , we demonstrate clinical success with cleft closure in an eye with chronic hypotony .
 cyclodialysis cleft is a rare clinical finding and therefore , reports on surgical repair techniques in the literature are limited . 
 additionally , hypotony can make repair technically challenging . 
 we share a novel , simple surgical approach to management of a case of chronic traumatic cyclodialysis cleft with a successful outcome . 
Introduction
Case report
Surgical technique
Discussion