EJO

ISSN 1120-6721
Eur J Ophthalmol 2017; 27 (3): 382-385
DOI: 10.5301/ejo.5000868

SURGICAL TECHNIQUE

Surgical repair of large cyclodialysis clefts

Jacob B. Gross1, Garvin H. Davis1,2, Nicholas P. Bell1,2, Robert M. Feldman1,2, Lauren S. Blieden1,2
1
Ruiz Department of Ophthalmology and Visual Science, McGovern Medical School at The University of Texas Health Science Center at Houston
(UTHealth), Houston, TX - USA
2
Robert Cizik Eye Clinic, Houston, TX - USA

Abstract
Purpose: To describe a new surgical technique to effectively close large (>180 degrees) cyclodialysis clefts.
Methods: Our method involves the use of procedures commonly associated with repair of retinal detachment
and complex cataract extraction: phacoemulsification with placement of a capsular tension ring followed by pars
plana vitrectomy and gas tamponade with light cryotherapy. We also used anterior segment optical coherence
tomography (OCT) as a noninvasive mechanism to determine the extent of the clefts and compared those results
with ultrasound biomicroscopy (UBM) and gonioscopy.
Results: This technique was used to repair large cyclodialysis clefts in 4 eyes. All 4 eyes had resolution of hypotony
and improvement of visual acuity. One patient had an intraocular pressure spike requiring further surgical inter-
vention. Anterior segment OCT imaging in all 4 patients showed a more extensive cleft than UBM or gonioscopy.
Conclusions: This technique is effective in repairing large cyclodialysis clefts. Anterior segment OCT more accu-
rately predicted the extent of each cleft, while UBM and gonioscopy both underestimated the size of the cleft.
Keywords: Anterior segment optical coherence tomography, Cyclodialysis cleft, Repair, Surgery

Introduction
Cyclodialysis clefts are rare and typically occur following
blunt ocular trauma or iatrogenic surgical injury. A cyclodialy-
sis cleft results from disinsertion of the longitudinal muscle
of the ciliary body from the scleral spur. This leads to the
formation of an additional aqueous drainage pathway be-
tween the anterior chamber and the supraciliary space. The
resulting communication can lead to an increased outflow of
aqueous and chronic ocular hypotony (1). Possible sequelae
due to ocular hypotony include a shallow anterior chamber,
cataract, ciliochoroidal effusion, optic disc edema, retinal and
choroidal folds, hypotony maculopathy, retinal vein engorge-
ment and stasis, and reduced visual acuity. In order to ad-
dress the resulting ocular pathology, surgical intervention is
often necessary.
Due to the infrequency of this pathology, the variability of
presentation, and the unpredictability of outcomes, a stan-
dardized protocol for repair is not generally agreed upon (2).
Furthermore, large cyclodialysis clefts (over 180 degrees) are
even rarer and more difficult to repair using traditional meth-
ods. We describe a novel surgical method for the treatment
of a series of large cyclodialysis clefts.
Accepted: August 20, 2016
Published online: September 13, 2016
Corresponding author:
Lauren S. Blieden, MD
6400 Fannin St., Suite 1800
Houston, 77030 TX, USA
lblieden@cizikeye.org
Methods
Preoperatively, all cases underwent anterior segment opti-
cal coherence tomography (AS-OCT) imaging using the CASIA
SS-1000 (Tomey, Nagoya, Japan) to define the extent of the
cyclodialysis cleft (Fig. 1, Tab. I). At the time of evaluation, this
device was not yet approved by the United States Food and
Drug Administration; thus informed consent was obtained
from all patients under an institutional review board (IRB)
approved protocol prior to AS-OCT evaluation. The IRB pro-
tocol was approved by The University of Texas Health Science
at Houston Committee for the Protection of Human Subjects.
In this series, 3 out of 4 eyes were phakic on presentation:
1 eye had a 3-piece intraocular lens (IOL) sewn to the sclera.
All of the phakic patients had at least 2 quadrants of zonuly-
sis. Two of the 3 phakic patients had vitreous prolapse into
the anterior chamber preoperatively.
Lens extraction was performed in all 3 phakic patients.
Viscodissection was used to lyse posterior synechiae. Iris
hooks were used to achieve better exposure, and capsular
tension hooks were placed as necessary to address zonular
weakness or absence in order to safely perform a curvilinear
capsulorhexis. In all 3 patients, the crystalline lens was soft
enough to aspirate using a bimanual setup. Anterior vitrecto-
my was performed as necessary prior to removal of the lens
material. A capsular tension ring was inserted into the apha-
kic capsular bag. The capsular tension hooks and iris hooks
were left in place to facilitate exposure during pars plana vit-
rectomy (PPV). The clear cornea incision and paracenteses
were closed with 10-0 nylon sutures.
Next, a PPV was performed with subsequent air-fluid ex-
change and 16% C3F8 injection. The iris and capsular hooks

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Gross et al 383

were removed once the aphakic capsule was noted to be sup-

ported by the bubble of C3F8. In the case of the patient with
the scleral-sutured IOL, acetylcholine chloride was injected
intracamerally to bring down the pupil and allow the C3F8
bubble to push the IOL anteriorly without allowing the gas to
escape into the anterior chamber.
Finally, lightly applied cryotherapy using the smaller ret-
ina cryopexy probe was delivered circumferentially approxi-
mately 1-2 mm behind the limbus. Applications were spaced
every other clock hour, including the entire extent of the cy-
clodialysis cleft as guided by preoperative AS-OCT imaging.
Subconjunctival dexamethasone and cefazolin were then in-
jected. The patient was kept in the supine position following
the procedure for up to 10 days to ensure closure of the cleft
and formation of stable scar tissue. Video 1 (available online
as supplementary material at www.eur-j-ophthalmol.com)
shows the technique in full with one patient from this series.

Fig. 1 - Large cyclodialysis cleft repair. (A) 3D anterior segment op-
tical coherence tomography (AS-OCT) image of large cyclodialy-
sis cleft of patient 1 before repair. (B) 3D AS-OCT image of large
cyclodialysis cleft of patient 1 after repair. (C) Schematic drawing
of cyclodialysis cleft repair technique demonstrates the aphakic
capsule with the capsular tension ring in a drumhead configuration
supported by the C3F8 bubble. CB = ciliary body.
Results
All 4 of our patients demonstrated complete closure and re-
turn of baseline visual acuity following this procedure (Fig.1),
with the exception of patient 4, who had successful closure of
the cleft but did not regain vision. Two of the 3 phakic patients

TABLE I - Patients and outcomes

Patient/eye Age, y/sex Visual acuity (Snellen) IOP, mm Hg Gonioscopy UBM AS-OCT
Preop Postop Preop Postop Preop Postop

1/OS 25/F 20/400 20/20 3 12 Angle recession Cleft present 300-degree cy- Cleft closed,
with cleft infero- inferotemporally clodialysis cleft angle recession
temporally, 3-4 with fluid in the and PAS present,
clock hours, with suprachoroidal choroidal effu-
angle closure space sion resolved
superonasally
due to vitreous
prolapse
2/OD 55/M 20/300 20/15 3 20 2 clock hours, Fluid in the >180 degree cy- Cleft closed
wide cyclodialysis suprachoroidal clodialysis cleft with strand of
cleft superiorly space, does not vitreous to angle
with vitreous delineate cleft superiorly, cho-
entrapped roidal effusion
resolved
3/OD 54/F CF at 2 ft, 20/400, 0 9 Enlarged ciliary Thickened 180-degree cy- Cleft closed,
eccentrically baseline body band along choroid on B- clodialysis cleft angle recession
the superior and scan, UBM not in the superior and PAS present,
temporal quad- performed due and temporal choroidal effu-
rants, concern- to discomfort quadrant sion resolved
ing for cleft from
clock hours 8-12
4/OD 13/M CF at 3 ft HM at 3 30a 1 quadrant of Cyclodialysis cleft 320 degrees of Closed on goni-
1 ft ciliary body dis- with supracho- cyclodialysis oscopy, did not
insertion superi- roidal fluid supe- cleft return for repeat
orly with obvious rotemporally AS-OCT imaging
instability
Patient was still in early postoperative period of tube shunt implantation, and only limited follow-up was available.
a

AS-OCT = anterior segment optical coherence tomography; CF = count fingers; HM = hand motion; IOP = intraocular pressure; PAS = peripheral anterior synechiae;
UBM = ultrasound biomicroscopy.

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384
have subsequently undergone placement of a 3-piece IOL into
the ciliary sulcus at 9 months and 12months postoperatively
with excellent visual outcomes. At 24 months, patient 2 re-
turned with a visual decline to 20/70 for which he underwent
Nd:YAG capsulotomy. His best-corrected visual acuity returned
to 20/20 after the procedure, with a stable refraction.
Closure of cyclodialysis clefts can result in an acute rise in
intraocular pressure (IOP) that may or may not be transient,
depending on the trabecular meshworks ability to recover.
In our series, only 1 out of 4 patients developed an acute rise
in IOP, resulting in vision loss. Given his age and the degree
of trauma, the patient was hospitalized for 3 days postopera-
tively to monitor his IOP every 12 hours. He was sent home
with topical medications on postoperative day 3 and told to
follow-up the next day; however, he missed this appointment
and returned on postoperative day 5 with an IOP of 56 mm
Hg and a decrease in vision to no light perception. After ur-
gent treatment in the clinic, including anterior chamber para-
centesis and release of C3F8, the patients vision returned to
count fingers, and he was rehospitalized for close observa-
tion. Ultimately, he did not recover trabecular function and
returned to the operating room for a glaucoma drainage de-
vice on postoperative day 11 (6 days after the IOP rise). He
was lost to follow-up 3 weeks after tube shunt implantation.
In cases of severe blunt trauma, these eyes are already at risk
for trabecular meshwork dysfunction and angle recession
glaucoma and should be monitored accordingly.
Discussion
Large cyclodialysis clefts are rare, and as such there is no
consensus as to the optimal surgical repair protocol. Numer-
ous methods for repair of smaller clefts have been suggested
with varied success, including a recent series from Xu et al (3)
that describes a similar technique of endotamponade with sil-
icone oil. However, the average size of their cyclodialysis clefts
was under 3 clock hours. We propose a novel method for large
cyclodialysis cleft repair that involves the use of procedures
commonly associated with repair of retinal detachment: PPV
and gas tamponade in conjunction with cryotherapy. The ba-
sis of this approach is to use an expansile gas in the posterior
segment to provide an outward force vector to reapproximate
the face of the ciliary body to the sclera in the area of the
cleft (Fig. 1). The use of a capsular tension ring serves sev-
eral purposes: 1) aids the mechanical tamponade of the cleft;
2) allows maintenance of a bicameral eye, thereby preventing
the gas bubble from escaping into the anterior chamber in
eyes where the lens complex is loose; and 3) provides sup-
port for secondary IOL insertion in the future. A light external
cryotherapy is then applied approximately 1mm behind the
limbus over the extent of the cleft, promoting permanent ad-
hesion between the ciliary body and the wall of the eye.
Cryotherapy or thermal laser alone are commonly used
to repair cyclodialysis clefts and have the added advantages
of being noninvasive and relatively safe. However, the use of
these therapies is generally limited to smaller cyclodialysis
clefts, where the amount of inflammation generated may be
adequate to elicit apposition and adhesion of the tissues.
Pars plana vitrectomy with gas tamponade increases the ap-
position of the ciliary body and sclera, improving the likelihood
Surgical repair of large cyclodialysis clefts
of cleft closure. Cryotherapy promotes the release of fibrin and
scar formation, allowing adhesion of the ciliary body with the
adjacent sclera. Combination treatment with cryotherapy and
PPV with gas tamponade has been reported, but the use of
this method on large cyclodialysis clefts (>180 degrees) is mini-
mally described. Two case reports describe successful closure
using a similar method in a 180-degree cleft and a 170-degree
cleft. Another case series also followed this treatment protocol
and achieved successful closure of 3 longstanding cyclodialysis
clefts, 2 small and 1 large (4-6). Our procedure varied with the
use of C3F8 injection in place of SF6, the use of a capsular ten-
sion ring, and the size of clefts treated.
Use of a capsular tension ring to repair a 300-degree cleft
has been described in a single case report. This technique
used a sulcus-fixated Cionni ring and posterior chamber IOL
as a tamponade with success after failed direct cyclopexy (7).
Our procedure differed in that we also used PPV with gas
tamponade of the capsular ring and cryotherapy, which pre-
cluded the need to suture in the capsular tension ring. At the
implantation of the secondary sulcus IOL in patients 1 and 2,
there was good support for the IOL. This stability was further
confirmed when the Nd:YAG capsulotomy was performed on
patient 2.
A potential concern with this method of repair is the in-
vasiveness of the procedure. Patients undergoing this proce-
dure often do not have adequate zonular support and would
need to undergo lensectomy with placement of a capsular
tension ring regardless. We did not have any patients with an
intact lenticulozonular apparatus, so we cannot assume that
this technique would be as successful in phakic patients with
intact zonules. As such, more conservative treatments, such
as medical management with atropine, laser, or cryotherapy
alone, should be considered first in phakic patients. Never-
theless, as blunt trauma is the most common cause for cy-
clodialysis cleft development, the likelihood a patient would
require future lensectomy is high. This is particularly true in
cases with substantial force, as would be expected for a very
large cleft to occur. A benefit of our technique is that the cap-
sular tension ring does not have to be sewn into place.
Pars plana vitrectomy is known to accelerate cataract
formation. In addition, lens extraction following substantial
trauma may not always be straightforward, and the need for
additional maneuvers such as iris hooks and capsular tension
rings is increased in these eyes. To this point, this technique
has only been used once the eye is no longer phakic. The
ability for gas to effectively compress the cleft in the most
anterior aspect of the posterior segment is potentially im-
proved with the aphakic capsule with a capsular tension ring
in place. This creates a drumhead-like configuration, which is
flatter and more pliable compared to a much larger crystal-
line lens. It also prevents the gas from escaping into the ante-
rior chamber and further widening the cleft (Fig. 1). Further
investigations will be needed to clarify the importance of the
lens status on the surgical success as well as the timing of IOL
insertion. There were 2 reasons why we planned staging the
IOL implantation: accuracy of IOL calculations and to ensure
stability of the capsular complex prior to insertion of IOL. In
the 2 cases where a secondary IOL was implanted, a 3-piece
lens was implanted into the sulcus without complication sev-
eral months after surgery, and both patients achieved 20/20
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Gross et al
best-corrected vision. Indeed, the second procedure took
about 10 minutes and only required topical and intracameral
anesthesia.
A final consideration for large cyclodialysis cleft repair
is diagnosis. In all 4 of our cases, AS-OCT revealed a more
extensive cleft than ultrasound biomicroscopy (supplemen-
tary Fig. 1, available online as supplementary material at
www.eur-j-ophthalmol.com) or gonioscopy, likely because
it is noncontact. Contact with a hypotonous globe may com-
press the angle, thereby underestimating the true extent of
the cleft. Accurate diagnosis provides a better ability to for-
mulate a surgical plan prior to operating. As such, we ad-
vocate the use of AS-OCT in conjunction with this surgical
technique.
Acknowledgement
The CASIA SS-1000 was loaned to Dr. Feldman by the Tomey
Corporation.
Disclosures
Financial support: Supported in part by National Eye Institute Vision
Core Grant P30EY010608, a Challenge Grant from Research to Pre-
vent Blindness to the McGovern Medical School at UTHealth, and
the Hermann Eye Fund.
Conflict of interest: None of the authors has conflict of interest with
this submission.
2016 Wichtig Publishing
385
Meeting presentation: Previously presented in part as a poster at
the 24th American Glaucoma Society Annual Meeting, February
27-March 2, 2014, Washington, DC, USA.
References
1. Ioannidis AS, Barton K. Cyclodialysis cleft: causes and repair.
Curr Opin Ophthalmol. 2010;21(2):150-154.
2. Ioannidis AS, Bunce C, Barton K. The evaluation and surgi-
cal management of cyclodialysis clefts that have failed to re-
spond to conservative management. Br J Ophthalmol. 2014;
98(4):544-549.
3. Xu WW, Huang YF, Wang LQ, Zhang MN. Cyclopexy versus vit-
rectomy combined with intraocular tamponade for treatment
of cyclodialysis. Int J Ophthalmol. 2013;6(2):187-192.
4. Ceruti P, Tosi R, Marchini G. Gas tamponade and cyclocryo-
therapy of a chronic cyclodialysis cleft. Br J Ophthalmol. 2009;
93(3):414-416.
5. Helbig H, Foerster MH. Management of hypotonous cyclodi-
alysis with pars plana vitrectomy, gas tamponade, and cryo-
therapy. Ophthalmic Surg Lasers. 1996;27(3):188-191.
6. Hoerauf H, Roider J, Laqua H. Treatment of traumatic cyclodi-
alysis with vitrectomy, cryotherapy, and gas endotamponade.
J Cataract Refract Surg. 1999;25(9):1299-1301.
7. Gupta S, Sagar P, Gogia V, Khokhar S, Dada T. Dual Endotem-
ponade for Extensive Long-standing Cyclodialysis Using Sul-
cus-fixated Cionni Ring and PCIOL. J Glaucoma. 2016;25(3):
e284-e287.