·Brief Report·
Scleral
buckling combined with internal cyclopexy for severe traumatic cyclodialysis
cleft in open globe injuries
Bo
Chen1, Gao-Xiang Wang2, Xian Zhang1, Hong Yang1
1Department
of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University
of Science and Technology,
2Department
of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of
Science and Technology, Wuhan 430030, Hubei Province, China
Correspondence to: Xian Zhang and Hong Yang. Department of Ophthalmology,
Tongji Hospital, Tongji Medical College, Huazhong University of Science and
Technology, Wuhan 430030, Hubei Province, China. zhangxiantjyk@163.com;
dr_yangh@aliyun.com
Received:
Abstract
This study aimed to evaluate the effect of scleral
buckling combined with internal cyclopexy on the treatment of severe traumatic
cyclodialysis cleft in open globe injuries (OGIS). This retrospective study
recruited 10 patients of 10 eyes. With our surgical intervention, all the 10
eyes achieved retinal and ciliary body anatomic re-attachment. The choroidal
ruptures in nine eyes were closed with complete choroidal reattachment.
Postoperative best-corrected visual acuity of nine eyes had various
improvements. The mean intraocular pressure was increased from 8.9±
KEYWORDS: cyclodialysis; ocular trauma; cyclopexy; scleral
buckling; pars plana vitrectomy
DOI:10.18240/ijo.2019.10.20
Citation:
Chen B, Wang GX, Zhang X, Yang H. Scleral buckling
combined with internal cyclopexy for severe traumatic cyclodialysis cleft in
open globe injuries. Int J Ophthalmol 2019;12(10):1649-1653
INTRODUCTION
Open globe injuries (OGIS) are a major cause of
blindness, causing approximately 203 000 such cases per year worldwide[1]. According to the different location of injuries, OGIS
can be divided into three zones by Ocular Trauma Classification Group (OTCG)[2]. Briefly, zones are defined as the cornea and limbus
(I); the anterior
With the development of microsurgical techniques,
pars plana vitrectomy (PPV), has dramatically improved the outcome of OGIS
involving the posterior segment[5-6].
However, some problems of OGIS with severe intraocular damage still deserve
attention. After received primary emergency ocular injury debridement suture,
in these patients, cyclodialysis, choroidal detachment and unclosed choroidal
rupture, which were usually accompanied by severe intraocular structure
abnormality (lens extrusion, iris defect and so on), could be defined as
“severe traumatic cyclodialysis cleft”. This kind of traumatic cyclodialysis
cleft is much more serious than the common traumatic cyclodiaysis cleft, which
occurs almost exclusively as a result of blunt ocular trauma[7-8]. In these patients, the unclosed choroidal rupture will
lead to the suprachoroidal space collection of tamponading agents, such as
silicone oil (SO). SO may migrate through the choroidal rupture into the
suprachoroidal space, which can possibly lead to persisent hypotony after
surgery[9-10]. When
cyclodialysis and choroidal detachment combined with choroidal rupture, the
hypotony will be more serious and impact patients’ visual function and
appearance. Our search of Medline database failed to reveal a similar report on
managing this kind of traumatic cyclodialysis cleft during the primary PPV. In
this study, we introduced an effective technique using the scleral buckling
combined with internal cyclopexy to treat the severe traumatic cyclodialysis
cleft in OGIS.
SUBJECTS AND METHODS
Ethical Approval
This retrospective study
included patients who consecutively attended the
The OGIS patients who had been diagnosed with severe
traumatic cyclodialysis cleft were included in our study. All these patients
had received an emergency ocular injury debridement suture in the
All the surgeries were carried out by the same
vitreoretinal ophthalmologist (Yang H) with
Figure 1 Diagrammatic
drawing of internal cyclopexy using double-armed straight needle A: A
Figure 2 The
surgical color photographs of patient two
A: The straight needle guided by
Follow-up examinations including BCVA, IOP, slit lamp
and ultrasound biomicroscopy (UBM) of the anterior segment and fundus
examination were performed 1 and 2wk, 1, 3, 6 and 12mo after surgery. SO was
removed 6-12mo after surgery for patients with retinal attachment and stable
normal IOP.
RESULTS
Our study included 10 eyes of 10 patients (8 men)
with a mean age of 41.6±16.7y (range from 3 to 66y). The causes of OGIS
included being hit by metallic stick, fish, wood bar, the explosion of
firecrackers, car accidents, cutting injury, and so on. Before the surgery, the
BCVA of four eyes were no light perception (NLP), four eyes were light
perception (LP) and two eyes were hand motion (HM). The location of the wound
was zone II in three eyes and zone III in seven eyes. The length of the wound
was 12.9±
The clinic data of 10 cases are presented in Table 1.
Four eyes received retinotomy, three eyes received choroidotomy and all the
eyes received SO tamponade because of the complicated and severe retinal
detachment. Four eyes have partial iris defect. Six eyes have lens extrusion
during the injury; the other four eyes have lensectomy because of the severe
cataract or dislocation of the lens. The extent of the cyclodialysis was
170.5°±74.9° (range from 80° to 360°). The postoperative follow-up was
longitudinally performed up to 12mo. The average follow-up time was 8.9±1.79mo
(range from 7 to 12mo).
Table 1 Clinical data of 10 patients with OGIS,
functional and anatomical status after surgical procedures
Case No. |
Age/ sex/ eye |
Trauma location (cause) |
Length of wound |
|
Length of follow up (mo) |
Unclosed choroidal rupture’s location |
Extent of the cyclodialysis |
Retinotomy/ choroidotomy |
Vision (BCVA) (preop./final) |
Ocular endotam- ponade |
IOP (preop./ postop., mm Hg) |
Anatomical outcome |
1 |
41/F/R |
Zone III (metallic stick) |
|
|
8 |
Before the equator |
130° |
No/no |
NLP/20/400 |
SO |
8/15 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO still in vitreous cavity) |
2 |
22/M/R |
Zone III (knife cut) |
|
|
7 |
Before the equator |
110° |
Yes/no |
LP/20/80 |
SO |
6/11 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO has been removed) |
3 |
43/M/R |
Zone II (wood bar) |
|
|
10 |
Across the equator to the posterior choroid |
80° |
Yes/yes |
LP/HM |
SO |
11/14 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO still in vitreous cavity) |
4 |
50/M/L |
Zone III (explosion of firecrackers) |
|
|
8 |
Before the equator |
230° |
Yes/no |
NLP/HM |
SO |
5/7 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO still in vitreous cavity) |
5 |
39/M/R |
Zone II (metallic stick) |
|
|
12 |
Before the equator |
135° |
No/no |
LP/20/100 |
SO |
12/18 |
Ciliary body re-attached, retina flat, chroidal rupture
close, chroidal flat (SO has been removed) |
6 |
3/M/L |
Zone III (wood bar) |
|
|
7 |
Across the equator to the posterior choroid |
360° |
Yes/yes |
NLP/NLP |
SO |
6/7 |
Ciliary body re-attached, retina flat, chroidal
rupture not fully closed, chroidal detachment not fully flat (SO still in
vitreous cavity) |
7 |
51/M/R |
Zone III (fish hit) |
|
|
11 |
Before the equator |
155° |
No/no |
LP/CF |
SO |
10/13 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO has been removed) |
8 |
50/M/R |
Zone III (car accident) |
|
|
9 |
Before the equator |
145° |
No/yes |
HM/20/200 |
SO |
11/15 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO has been removed) |
9 |
51/M/L |
Zone II (car accident) |
|
|
7 |
Before the equator |
160° |
No/no |
NLP/CF |
SO |
12/21 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO has been removed) |
10 |
66/F/R |
Zone III (metallic stick) |
|
|
10 |
Before the equator |
200° |
No/no |
HM/20/400 |
SO |
8/13 |
Ciliary body re-attached, retina flat, chroidal
rupture close, chroidal flat (SO has been removed) |
BCVA: Best-corrected visual acuity; IOP: Intraocular
pressure; NLP: No light perception; HM: Hand motion; SO: Silicone oil; LP:
Light perception; CF: Counting fingers.
Postoperatively, the ciliary body was re-attached in
all the eyes, as confirmed by UBM at the end of follow-up. The choroidal
ruptures in nine eyes were closed with complete choroidal reattachment (Figure
3, Table 1). In the other one eye, although the choroidal rupture was not fully
closed, the choroidal detachment was less extensive than pre-operation. After
the SO tamponade for 6 to 12mo, all the eyes achieved retinal anatomic
re-attachment, which included one eye undergoing re-operation due to the
recurrence of retinal detachment in SO. Six eyes received SO removal without
complications, two eyes still had SO tamponade (Figure 3B, Table 1) and two
eyes became SO-dependent eyes due to the IOP<
Figure 3 The fundus photographs of representative
patients at the last follow up visit
A: The fundus photograph
of patient five. Red arrow shows the choroidal rupture was tightly closed. SO
had already been removed. B: The fundus photograph of patient three. The
choroidal rupture (red arrow) was surrounded by white scars and was also
closed. SO was still in the vitreous cavity.
DISCUSSION
Severe OGIS, especially combined with severe traumatic
cyclodialysis cleft, is still a complicated challenge even for current PPV. In
our retrospective study, although the OGIS were complex and serious, the BCVA
was improved in most eyes. All the 10 patients who received internal cyclopexy
combined with scleral buckling successfully achieved ciliary body reattachment
and most of the choroidal ruptures were closed. Only two eyes became
SO-dependent eyes with hypotony. We speculate that there are some reasons
causing SO-dependence: 1) the extensive retinal defect caused by primary severe
and complicated injury may increase the exposure of the choroid which can lead
to hypotony; 2) the extensive detachment of ciliary body in these two cases may
reflect more severe ciliary damage causing irreversible reduction of aqueous
humor; 3) traumatic cyclitic membranes in child also may permanently inhibit
the formation of aqueous humor.
There are some differences between traditional
techniques in repairing the ciliary body detachment, most of which use scleral
flap for external direct cyclopexy to reattach ciliary body[7-8,11-12]. Briefly, a
scleral flap is made at the region of the cyclodialysis and the detached
ciliary body can be directly visualized. The ciliary body is sutured under
direct vision to the sclera, followed by suturing the scleral flap both using
10/0 nylon sutures. Compared to conventional external direct cyclopexy, our
techniques have some advantages: 1) There is no need to prepare scleral flap
which may interfere the three-port of scleral incision for vitrectomy. 2) Our
technique is suitable for patients with extensive cyclodialysis, which will
lead to instability or/and ischemia of the eyeball due to large extent of
scleral flap if treated by the traditional external cyclopexy. 3) This method
is especially suitable for aphakia, which allows us to directly observe and
suture the cyclodialysis without densely or inadequately suturing. Our method
of internal cyclopexy is similar with that Wang et al[13]
reported. However, we made some modifications due to the aphakia in most of the
patients. First, we used scleral depression to precisely locate the region of
the cyclodialysis. Meanwhile, the pars plana sclerotomy was replaced by limbus
as the location of piercing into the eye which did not cause iatrogenic cyclodialysis
and did not need suturing. Thus, with these modifications, our method is more
convenient and safe for the severe cyclodialysis.
There are some favorable surgical techniques to
repair traumatic cyclodialysis cleft that included capsular tension ring,
intraocular lens, cryotherapy or endolasercoagulation combined with cyclopexy
and PPV combined with vitreous cavity endotamponade[8,12,14-16]. However,
all of these techniques are not suitable for these OGIS patients who have
cyclodialysis, choroidal detachment and unclosed choroidal rupture. The
choroidal rupture may become rigid, and lead to SO migration into
suprachoroidal spaces which may cause long-term hypotony[10].
Thus, choroidal detachment will not recover unless we fix both choroidal rupture
and cyclodialysis in severe OGIS. In our technique, firstly we use internal
cyclopexy to reattach the ciliary body, which can block the communication from
the anterior chamber to suprachoroidal space and stabilize the detached
choroid. Secondly, the scleral buckling was followed with the internal
cyclopexy to close the choroidal rupture and enhance choroidal reattachment. As
we expected, our study data demonstrated that scleral buckling combined with
internal cyclopexy could effectively reattached ciliary body, close the
choroidal rupture, minimize choroidal detachment, and eventually prevent
hypotony. Our study also has some limitations. First, our study is
retrospective and the number of patients is relatively less, which may lead to
selection bias. Second, our investigation did not include a control group that
did not allow the comparison among different surgical techniques. Third, the
limited cases also restricted the statistical analysis, such as for
investigating the success rate of surgery and risk factors of SO-dependent.
However, the preliminary results of our study are encouraging.
In conclusion, our study shows the internal direct
cyclopexy combined with scleral buckling is an effective way for repairing the
severe traumatic cyclodialysis cleft in OGIS.
ACKNOWLEDGEMENTS
Conflicts of Interest: Chen B, None; Wang GX, None; Zhang X, None; Yang
H, None.
REFERENCES