Ultrasound biomiscroscopy in the diagnosis and management of cyclodialysis clefts :Muna Bhende, T Lekha, L Vijaya, Lingam Gopal, Tarun Sharma, Sunil Parikh, Indian Journal of Ophthalmology

ORIGINAL ARTICLE
Year : 1999 | Volume : 47 | Issue : 1 | Page : 19--23

Ultrasound biomiscroscopy in the diagnosis and management of cyclodialysis clefts

Muna Bhende, T Lekha, L Vijaya, Lingam Gopal, Tarun Sharma, Sunil Parikh
Medical and Vision Research Foundation, 18 College Road, Chennai, India

Correspondence Address:
Muna Bhende
Medical Research Foundation, 18 College Road, Chennai - 600 006
India

Abstract

Purpose: To report the role of Ultrasound Biomicroscopy (UBM) as a tool in the diagnosis and management of cyclodialysis clefts. Methods: Six eyes of 6 patients with hypotony and suspected or diagnosed cyclodialysis clefts underwent UBM evaluation. Post-treatment UBM was performed in four eyes to assess the effect of the treatment. Results: Cyclodialysis clefts were accurately diagnosed and delineated in 6 eyes by UBM. Complete closure was documented after treatment in 3 eyes, and a residual cleft in one eye. These findings were compared to gonioscopic findings. Conclusions: UBM is a safe, accurate and noninvasive diagnostic tool in the diagnosis of cyclodialysis clefts and is of particular use when other conventional methods of diagnosis are inconclusive.

How to cite this article:
Bhende M, Lekha T, Vijaya L, Gopal L, Sharma T, Parikh S. Ultrasound biomiscroscopy in the diagnosis and management of cyclodialysis clefts.Indian J Ophthalmol 1999;47:19-23

How to cite this URL:
Bhende M, Lekha T, Vijaya L, Gopal L, Sharma T, Parikh S. Ultrasound biomiscroscopy in the diagnosis and management of cyclodialysis clefts. Indian J Ophthalmol [serial online] 1999 [cited 2023 Nov 28 ];47:19-23
Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1999/47/1/19/22802

Full Text

Cyclodialysis is disinsertion of the longitudinal ciliary muscle fibres from the scleral spur resulting in a cleft which establishes a communication between the anterior chamber and the suprachoroidal space.[1] It can occur accidentally following trauma, iatrogenically during intraocular surgery (particularly with a scleral section or tunnel, or during iris manipulation) and as an intended treatment for glaucoma.[1] It results in hypotension as a result of the efflux of aqueous from the eye via the suprachoroidal space[2],[3] as well as decreased aqueous production due to diminished blood supply to the ciliary body.[1] The sequelae of cyclodialysis include shallow anterior chamber, hypotony maculopathy and possibly loss of vision in case of prolonged hypotony. These, however, can be reversed with prompt diagnosis and treatment.[1] Clefts can close with restoration of normal intraocular pressure either spontaneously or with medical treatment.[1] Clefts which do not fall in the above category need treatment either by direct laser coagulation,[1],[4],[5] ciliochoroidal diathermy,[1] cryopexy[1] or surgery.[1],[6] These methods require precise identification of the cleft. Though gonioscopy can delineate clefts in most instances, it may be difficult to visualize them in recently operated or injured eyes due to extreme hypotony, distorted anatomy or media opacities like Descemet's folds, corneal scars, or hyphema.[1],[8] Other methods of visualization include use of miotics,[1] intracameral viscoelastics,[1] and intracameral fluorescein injection[7] which, however, are of limited use in the previously described instances.

Recently ultrasound biomicroscopy (UBM) has been used with considerable success[8-10] to detect and monitor management of cyclodialysis clefts. A non-invasive method developed by Pavlin et al,[11],[12] it involves the use of high-frequency (50 MHz) transducers incorporated into a clinical B-scan device to accurately image anterior segment structures in vivo. It has proved useful in understanding the pathophysiology of various anterior segment disorders which may not otherwise be visualised clinically.[11],[12] We used the ultrasound biomicroscope in 6 eyes of 6 patients with hypotony, where cyclodialysis clefts were either diagnosed or suspected on gonioscopy, to confirm or detect the condition and to monitor the response to treatment.

Materials and Methods

Six eyes of 6 patients with hypotony, either diagnosed gonioscopically or suspected due to cyclodialysis clefts were subjected to UBM. Four eyes showed evidence of cyclodialysis on gonioscopy, and two did not, despite a high index of suspicion. These clefts occurred following blunt trauma in 4 eyes, following cataract surgery with intraocular lens implantation in one eye and following surgical iridectomy in one eye. We used the UBM (Humphrey Instruments-840) with a 50 MHz transducer with a resolution of 50 mm, and tissue penetration of 4-5 mm. The patient was kept supine and the eye was topically anaesthetised with proparacaine (0.75%). A polymethyl methacrylate (PMMA) cup of suitable size was used to keep the eye open, 2.5% methyl cellulose was used to fill the cup and the probe was immersed in it up to approximately 2-3 mm above the ocular surface. The probe was manually moved in different meridians and cross-sectional images of the anterior segment, especially the angle, were studied.

Results

The clinical, gonioscopic, and UBM findings of the 6 cases are summarised in the table. A classic cyclodialysis cleft was diagnosed on UBM as an echolucent gap between the low-reflective ciliary body and the high-reflective sclera, which gave rise to a passage connecting the anterior chamber with the suprachoroidal space [Figure:1]. Two cases of special interest are highlighted below.

Case 2

A 73-year-old female was under conservative treatment for persistent uveitis following cataract surgery with intraocular lens implantation and subsequent Yittirum-Aluminium-Garnet (YAG) capsulotomy in the right eye. When seen on routine examination a year post-operatively, vision in the right eye was 6/36, N12. There were Descemet's folds in the cornea, iris bomb� and ring synechiae. The posterior chamber intraocular lens (PCIOL) was in place. Applanation tension was not recordable and retinal examination revealed disc edema and hypotony maculopathy along with an epiretinal membrane. There was a peripheral shallow choroidal detachment. Gonioscopy could not visualise the angle due to Descemet's folds and flat anterior chamber. The left eye was normal except for early cataract. UBM of the right eye showed peripheral anterior synechiae, a retrocorneal membrane, and a cyclodialysis cleft from 11-1:30 o' clock with ciliary body detachment and suprachoroidal effusion [Figure:2]. The patient underwent a YAG iridotomy to deepen the anterior chamber. The gonioscopy following iridotomy showed cyclodialysis cleft from 11 to 1 o' clock. The patient underwent IOL removal, vitrectomy, epiretinal membrane removal and belt buckling along with trans-scleral cryopexy to the cleft. Six weeks postoperatively, her vision was 6/36, N 8 with a decrease in Descemet's folds, deepening of the anterior chamber and an intraocular pressure (IOP) of 15 mm Hg. Fundus examination showed a normal disc, attached retina and good encirclage effect. There was no evidence of hypotony maculopathy. UBM showed closure of the cleft by reattachment of the ciliary body to the scleral spur, except for a small gap at 1:30 o' clock position. Repeat UBM a month later when she presented with visual acuity of 6/24, and intraocular pressure of 4 mmHg showed persistence of the 1:30 o' clock cyclodialysis cleft [Figure:3] with suprachoroidal effusion from 1 to 4 o' clock and 360� traction on the ciliary processes and pars plana.

Case 3

A 28-year-old male presented with a history of blurred vision following blunt injury to the left eye a month earlier. Best corrected vision in the left eye was counting fingers at 1 meter. The lens was subluxated temporally with superonasal zonular dehiscence. IOP was not recordable. Gonioscopy revealed a cyclodialysis cleft from 11 to 1 o' clock and a doubtful area from 6 to 8 o'clock. The retina showed changes of hypotony maculopathy. The right eye was normal.

UBM revealed a convex iris, peripheral shallow anterior chamber and cyclodialysis cleft from 11 to 1 o' clock and 6 to 8 o' clock, communicating with the suprachoroidal space. An attempt was made to close the cleft using argon laser but this was unsuccessful due to collapse of the cleft during gonioscopy. The patient did not report until 3 months later when vision had improved to 6/9, N6 and IOP was 21 mm Hg. Gonioscopy showed a cyclodialysis cleft from 8 to 10:30 o' clock and 12.00 to 1 o' clock. UBM showed that the cleft extended from 8 to 1 o' clock with iris apposition from 10:30 to 11 o' clock. The region from 10:30 to 11 o' clock communicated with the suprachoroidal space which showed evidence of suprachoroiddal fluid [Figure:4]. The patient underwent argon laser photocoagulation to the entire extent of the cleft and is due for follow-up.

Discussion

The ultrasound biomicroscope has proved to be a useful tool in managing the anterior segment of the eye, particularly in cases where media opacities preclude conventional examination techniques. Cyclodialysis clefts which are well described as a cause for hypotony are often missed gonioscopically for various reasons.[1],[8] UBM has been described in these situations as supplementing gonioscopic and clinical findings. Gentile et al[8] studied UBM findings in six traumatic cyclodialysis clefts, none of which were visualised gonioscopically due to hyphema (2 cases) and iris bowing (4 cases). Their series included a follow-up UBM of 3 cases, 1 in which the cleft closed spontaneously, and 2 which underwent active treatment. Karwatowski and Weinreb[9] reported a case of cyclodialysis cleft occurring after phacoemulsification through a scleral tunnel. Though initially visible on gonioscopy, after 2 attempts to treat the cleft and apparent closure on gonioscopy, the UBM revealed a residual cleft accounting for persistent hypotony. Jurgens and Pujol[10] also reported the usefulness of UBM in evaluating the ciliary body in cases of blunt trauma. Berinstein et al[13] reported detection of clefts in two eyes with anterior segment trauma, the first case not visible gonioscopically due to corneal edema, and the second showing an increased extent of the cleft on UBM.

Persistent hypotony can occur due to a variety of reasons other than cyclodialysis clefts, including choroidal effusion, wound leaks, retinal detachment, retrolenticular membranes and chronic inflammation.[1] Hence it is important to be able to identify this pathology. Inability to perform gonioscopy or visualize the angle due abovementioned reasons underscore the value of UBM as an important diagnostic aid. In all 6 eyes in our series, UBM was able to precisely define the extent of the cleft and associated suprachoroidal effusion. In case 5, the cleft was not seen gonioscopically due to extreme hypotony. In 5 of the 6 cases, the extent of the cleft was more precisely demonstrated by UBM than gonioscopy, thus helping in more definite treatment. UBM was found specifically useful in eyes where the cleft was closed anteriorly by iris contact (Case 3) or retrocorneal membranes (Case 2) and hence not visible gonioscopically, but remained open posteriorly with communication into the suprachoroidal space. In case 3, the cleft seen on gonioscopy was noted to be closed posteriorly, thus sealing off the suprachoroidal space. Patent clefts may be seen in normotensive or hypertensive eyes, where it has been walled off by suprachoroidal space adhesions.[1] However, in case 5, repeat UBM after treatment revealed a new cleft which had not been detected earlier. This can be due to the rare occurrence of spontaneous opening and closing of clefts which produce fluctuations in IOP, and usually presage ultimate closure.[1]

Management of cyclodialysis clefts associated with hypotony is aimed at preventing the egress of aqueous via the suprachoroidal space. Options include cycloplegia,[14] laser photocoagulation,[4],[5] cyclo diathermy,[1] cryopexy,[1] and surgical repair.[6,10] All 6 eyes in our series underwent treatment for cleft closure. One underwent laser photocoagulation, and the remaining 5 underwent laser or cryopexy to the cleft as part of a vitreoretinal surgical procedure for associated abnormalities. In one case (Case 1), the patient had already undergone an encirclage procedure which was unsuccessful. UBM delineation of the cleft aided the precise identification and treatment resulting in cleft closure and normalisation of the IOP.

UBM is a safe, non-invasive and accurate investigational tool that can aid the diagnosis and monitor the management of cyclodialysis clefts, especially when a view of the anterior segment is limited[14].

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