Retina Today - Retina Pearls: Ultrasound Biomicroscopy-Guided Surgical Intervention for Cyclodialysis Clefts (May/June 2011)

摘要

In this issue of Retina Today, Mehran Taban, MD; Christine Sonnie, RN; Brandy C. Hayden, BS; and Jonathan E. Sears, MD, provide surgical pearls for using ultrasound biomicroscopy for the diagnosis and surgical management of cyclodialysis clefts in a series of patients with hypotony treated with external cycloplexy with radial sutures. We extend an invitation to readers to submit pearls for publication in Retina Today. Please send submissions for consideration to Dean Eliott, MD (dean_eliott@meei.harvard.edu); or Ingrid U. Scott, MD, MPH (iscott@psu.edu). We look forward to hearing from you. a??Ingrid U. Scott, MD, MPH; and Dean Eliott, MD Ocular hypotony is associated with significant visual dysfunction depending on its severity and duration. One etiology of hypotony is cyclodialysis cleft (CDC), a disinsertion of the longitudinal ciliary muscle fibers from the scleral spur. Originally described as a planned surgical treatment for intractable glaucoma, CDC may be observed following trauma or as an inadvertent surgical event from a variety of procedures involving iris or angle manipulation such as goniotomy, trabeculectomy, phacoemulsification, intraor extra-capsular cataract extraction, iridectomy, and sclerotomy. It can also be present in cases of anterior proliferative vitreoretinopathy (PVR) with traction on the ciliary body causing an occult CDC.1 DIAGNOSIS The diagnosis of CDC requires clinical suspicion, as its signs are often limited; these can include a combination of a shallow anterior chamber, a peaking of the pupil, partial mydriasis, or just hypotony. Gonioscopy can identify a CDC, but it is often limited, especially for smaller clefts, in cases with factors precluding an adequate view, such as hyphema, corneal edema, and shallow anterior chamber. Immersion B-scan has been used with limited success.2 Magnetic resonance imaging (MRI) has also been attempted; however, its high cost, limited accessibility, and relative poor resolution make it an unacceptable choice.3 Even scleral transillumination has been described.4 Ultrasound biomicroscopy (UBM) can provide high-resolution (37 ??m) images of angle structures, compared with a resolution of approximately 190 ??m for standard Bscan ultrasound. UBM has been used to diagnose CDCs,5-8 although there are limited reports of its use in diagnosing and guiding the management of CDC in a large series. We are unaware of the use of external direct cyclopexy in previously reported series. The purpose of this study, therefore, is to evaluate UBM in guiding the diagnosis and surgical management of CDCs in a small series of patients with hypotony. The surgical technique employed to close the CDCs was external cycloplexy with radial sutures. METHODS After receiving approval from the Cleveland Clinic institutional review board, we performed a retrospective analysis of patients with hypotony (intraocular pressure [IOP]