gms | German Medical Science

21. Jahrestagung der Retinologischen Gesellschaft gemeinsam mit dem
8. Symposium der International Society of Ocular Trauma

Deutsche Gesellschaft für Retinologie
International Society of Ocular Trauma

19.06. - 22.06.2008, Würzburg

Trauma-induced Ocular Hypotony and Approaches to Chronic Iridodialysis, Cyclodialysis, Angle Recession, and Uveal Prolapse

Meeting Abstract

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  • William E. Sponsel - San Antonio/Texas, USA

Retinologische Gesellschaft. International Society of Ocular Trauma. 21. Jahrestagung der Retinologischen Gesellschaft gemeinsam mit dem 8. Symposium der International Society of Ocular Trauma. Würzburg, 19.-22.06.2008. Düsseldorf: German Medical Science GMS Publishing House; 2008. DocISOTRG2008V089

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Veröffentlicht: 18. Juni 2008

© 2008 Sponsel.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen ( Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.



Purpose: Preoperative ultrabiomicroscopy provides the trauma surgeon with extraordinarily useful 3-D mapping information, including spatial information that allows precise placement of sclerostomies, and in determining which zones of cyclodialysis may require scleral spur resuturing. In this talk we review the course of several patients presenting during the same month using a 50 MHz UBM transducer which can reveal hidden anatomy and pathology abutting the anterior segment, including the cornea, iris, sclera, and ciliary body.

Methods: The imaging system used for these patients has a lateral and axial resolution of 50 microns, and a user switchable focal length. The scan characteristics of the UBM were: scan Rate 8 Hz, sampling resolution 5 microns, scan width 2.5 to 5 mm, and scan height 2.5 to 10 mm.

Results: Case 1: 54 y.o. male military veteran with prior enucleation of right and severe trauma to left eye after being kicked in the face by a horse 10 years previously. Uses stick for ambulation.

Findings include traumatic angle recession, large circinate supraciliary effusion, chronic hypotony, maculopathy, dense cataract, a calcified pupillary membrane, phacodynesis/zonulolysis, posterior iris fixation, and now pre-phthisical squaring off of the globe OS.

PMH: Diabetes, Hypertension, Heart disease, Multiple facial fractures, disfigured

Acuity: OD enucleated, OS 20/400-HM

Autorefract: OS: -9.75 + 1.00x30

Tonometry: OS: too soft to applanate

Slit lamp exam: Significant angle disruption superiorly and nasally associated with chronic hypotony.

Gonioscopy: Widespread gross recession but no visible uveoscleral detachment (massive sealed-off cyclodialysis).

UBM findings: Extensive, broad, but shallower effusions from 9 o’clock to 2 o’clock with massive uveal swelling. More anterior cylindrical deep closed cyclodialysis/recession from 2 o’clock to 5 o’clock

Operative Procedure: Dense cataract was removed very carefully via clear cornea approach. All synechia were left in place for phaco. The brittle fibrotic pupillary membrane was removed along with capsule using a quick circular capsullorhexis inside the margins of the 360 degree posteriorly syneched large pupil. Low-infusion phaco was used, and IA performed manually to preserve capsule. Foldable acrylic MA60 lens was gently inserted. Drainage of Old Effusions: Greater than 2ml of supraciliary straw-colored effusate was drained via several strategically placed sclerostomies, facilitated by alternate AC-BSS exchange. The scleral spur was not plicated with sutures or cryo since intraocular hydrostatic pressure alone held the uveal tissue in place.

Reduction/replacement of Spur: the posteriorly displaced scleral spur, scarred in place inferonasally for >6 clock hours, was then repositioned by grasping the pupillary margin beneath the limbus with two pairs of forceps, bringing the iris back into view and re-establishing a central pupil.

Course of Management: Within 2 days of procedure, patient began making aqueous again. On day 3, he presented to the ER with IOP>60mmHg and required rapid medical equilibration. Vision >20/100, can now read, ambulates freely, but IOP fluctuates and he will eventually need tube shunt to prevent vacillation and maximize function.

Case 2: Came into clinic same time as the previous patient.

81 yo man with painful OS and stromal edema and 20/200 acuity. Referred as a presumptive Fuch’s dystrophy. Underwent extracapsular cataract extractions OU 5 yrs previously. Has had chronic intermittent hypotony OS since 1995.

PMH: Diabetes, CAD, CVA

Acuity: OD 20/20; OS 20/200

IOP: OD 13mmHg; OS 0 mmHg

Pupils: 3.5—3mm OU; +1 RAPD OS

Slit lamp exam: Cornea: OS slight wrinkling on epithelial side. Fine pigment on endothelial side.

Macular folds

Evidence of significant angle disruption inferiorly and temporally

Cyclodialysis associated with hypotony

Gonioscopy: Visible uveoscleral detachment 11-12 o’clock

UBM findings: Thinnest area of uveal detachment at 12 o’clock and 6 o’clock Widest area at 4 o’clock

Initial Assessment: It was determined that patient would probably need to undergo drainage from a pars plana sclerostomy at around the 4 o’clock position. However, since the actual 12 o’clock cyclodialysis cleft was associated with the least adjacent effusion of all, conservative measures to seal off the cleft were given a chance. Patient was given cyclogyl 2% four times daily OS and surgery was deferred for one month.

Remarkable development!

Despite UBM-verified chronic supraciliary effusion and repetitive IOP measurements of 0mmHg with macular folds OS, there had been spontaneous resolution since last visit when cycloplegic therapy was commenced. Planned pre-op slit lamp exam IOP measured 9-10 mmHg OS with clear cornea and no visible macular folds. BCVA ever documented after cataract had been 20/40; Now it measured 20/15 OS. Permanent surgical repair of cleft performed electively later to allow d/c of mydriatic.

Case 3: 8 y.o. boy s/p BB gun injury OD

Iris was detached and scrolled nasally and encased in fibrin and vitreous with half the zonule destroyed temporally.

Patient was still phakic with clear lens behind AC debris, but with persisting hypotony 11 days since injury, had no apparent macular function (<20/400), and was painful, agitated, and at risk for rebleed.

UBM: Showed large cyclodialysis and bilateral adjacent supraciliary effusions, with extensive angle recession extending beyond the ends of the cyclodialysis cleft.

Procedure: Repair of cyclodialysis cleft, iridodialysis, vitrectomy, transscleral drainages, Ahmed implant, scleral reinforcement graft OD

Outcome: Child now has pupil with sphincter function, visual acuity uncorrected of 20/30, has full peripheral visual function, IOP consistently 16 mmHg without medication. Disc and Macula appear normal.

Conclusions: Proper realignment of tissue planes after Intermediate segment trauma is greatly assisted by UBM. Restoration of anatomic uveoscleral union is necessary to reestablish ocular integrity. Loculated fluid behind extensive stretches of posteriorly displaced scleral spur requires reduction of synechia and repositioning of anterior uveal tissue. Once uveoscleral juxtaposition is established, gross IOP elevation is inevitable once aqueous production starts. For this reason, prophylactic shunt placement may be prudent, especially in a child. In instances where a short segment of detached spur remains aligned with normal attachment site, pharmacologic cycloplegia may induce a narrow cleft to reseal, allowing resorbtion of fairly massive adjacent circinate supraciliary effusions. Ultrabiomicroscopy can be extremely useful in determining the best approach.