Cyclodialysis Cleft after Intravitreal Injection

A cyclodialysis cleft results from the separation of the longitudinal fibers of the ciliary body muscle from the scleral spur, leading to a direct connection between the anterior chamber and the suprachoroidal space. Cyclodialysis clefts can lead to ocular hypotony due to the abnormal new pathway of aqueous humor drainage into the suprachoroidal space and possible reduction of aqueous humor formation due to decreased ciliary body perfusion [1]. Intravitreal injections (IVIs) have become one of the most commonly performed ophthalmic procedures worldwide. The estimated number of IVIs in 2016 worldwide was 20 million, and in the USA, it was 7 million [2]. These numbers have continued to increase due to expanding indications for IVIs in addition to the greater availability of medications, including anti-vascular endothelial growth factors, antibiotics, antivirals, antifungals, and steroids [3]. Although IVIs are generally well tolerated, sight-threatening complications, including endophthalmitis, retinal detachment, and retinal vasculitis, can occur [3, 4]. Hypotony is a rare complication, with a few reported cases of hypotony following IVIs, mostly due to scleral wound leakage or inadvertent bleb formation [5‒7]. Here, we present a case of hypotony due to a cyclodialysis cleft following an IVI that resolved after ab-interno repair of the cyclodialysis cleft.

A 53-year-old man was referred to the glaucoma service for evaluation of persistent hypotony of the right eye. His past ocular history was notable for diabetic retinopathy in both eyes, for which he received multiple IVIs of aflibercept. The patient underwent bilateral uncomplicated cataract surgery 3 years prior to presentation. He denied any history of trauma. Three months before presentation, the patient received an IVI of aflibercept in the right eye, and 2 days later he started to complain of decreased vision. The patient was thought to have iridocyclitis and was started on topical prednisolone acetate 1% eye drops.

On initial examination, the patient’s best corrected visual acuity (BCVA) was 20/200 in the right eye and 20/125 in the left eye. Intraocular pressure (IOP) was 2 mm Hg in the right eye and 15 mm Hg in the left eye. Slit-lamp examination of the right eye revealed a deep and quiet anterior chamber with significant corneal edema and Descemet’s membrane folds. On gonioscopy of the right eye, a cyclodialysis cleft nasally from 12:30 to 4:00 was noted. Examination of the left eye was unremarkable. Anterior segment optical coherence tomography (AS-OCT) confirmed the presence of the cyclodialysis cleft with ciliary body detachment and a direct communication between the anterior chamber and the suprachoroidal space (Fig. 1). The steroid eye drop was tapered, and atropine sulfate 1% three times a day was started.

Given the chronicity and the extent of the cleft, ab-interno direct cyclopexy was performed. After marking the extent of the cyclodialysis cleft, conjunctival peritomy was completed. A temporal clear corneal incision was made, and then the anterior chamber was filled with an ophthalmic viscoelastic device. Three partial-thickness scleral grooves adjacent to the cleft and 1.5 mm posterior to the limbus were made using a diamond blade. A double-armed 10-0 polypropylene suture on an STC-6 needle was passed through the corneal incision. A bent 25-gauge needle was passed through the external scleral groove into the sclera and ciliary body. The polypropylene suture was inserted into the lumen of the 25-gauge needle and externalized through the scleral groove. The suture was tied, and the knot was buried into the scleral groove. Two more additional sutures were done using the aforementioned technique. The closure of the cyclodialysis cleft was confirmed using intra-operative OCT. The conjunctival peritomy was then closed using an 8-0 Vicryl suture (online suppl. Video 1; for all online suppl. material, see https://doi.org/10.1159/000542200).

In the first post-operative week, the VA of the right eye was 20/200 with an increased IOP of 33 mm Hg, so latanoprost and dorzolamide/timolol combination eye drops were started to control the IOP. In post-operative month 2, IOP was 12 mm Hg on the same glaucoma medications, so the decision to stop the IOP-lowering drops was made. Three months after the surgery, IOP continued to be controlled at 16 mm Hg on no glaucoma medications, with no signs of hypotony noted in the exam and a mild VA improvement to 20/150.

Cyclodialysis clefts occur due to disinsertion of the ciliary body from the sclera, creating an aberrant pathway for aqueous drainage into the suprachoroidal space [1]. Cyclodialysis clefts are a rare complication of ocular trauma or surgeries. Cyclodialysis may occur after blunt trauma due to sudden anteroposterior globe compression with rapid equatorial expansion, causing detachment of the ciliary muscle from the scleral spur. A previous retrospective study estimated the incidence of cyclodialysis clefts after blunt ocular trauma at approximately 2% [8]. Cyclodialysis clefts have been reported to occur following various intraocular surgeries, including cataract surgery, trabeculectomy, iridectomy, and goniotomy [9].

The overall incidence of complications associated with IVIs is low [10]. Hypotony following IVIs is even more rare. A wound leak causing hypotony was previously reported on the first day after an IVI for choroidal neovascularization. A Seidel-positive area and a bleb formation were observed over the site of injection, which resolved after 3 days of conservative treatment with IOP and VA returning to baseline [11]. Similarly, a 70-year-old woman with a prior history of pars plana vitrectomy developed self-resolving hypotony following IVI using a 30-gauge needle [5]. Rodrigues and associates described another patient who developed hypotony and choroidal detachment after IVI that required surgical closure of the patent scleral wound [12]. In the previously mentioned reports, the cause of hypotony was sclerotomy wound leak. However, in our case, no evidence of a patent sclerotomy was noted.

In a report by Lee and colleagues, a 67-year-old man developed hypotony and vitreous hemorrhage 3 days after IVI of Bevacizumab. Although gonioscopy did not reveal cyclodialysis, high-frequency ultrasound biomicroscopy (UBM) showed a posterior cyclodialysis cleft with a direct communication between the posterior chamber and the suprachoroidal space. Closure of the cyclodialysis cleft occurred spontaneously in around 2 months with medical therapy [13]. Similar to our patient, this case reports a cleft that allowed communication between the suprachoroidal space and the posterior chamber in that case and the anterior chamber in ours. It is recommended to administer IVIs approximately 3.5–4 mm posterior to the limbus to avoid damage to the lens, ciliary body, or retina. However, anterior IVIs, early injection while introducing the needle, or continued injection on needle withdrawal may cause ciliary body detachment and cyclodialysis cleft [13].

Proper diagnosis and timely intervention of cyclodialysis clefts are important as ocular hypotony may be associated with complications such as cataract, optic disc swelling, and hypotony maculopathy, leading to decreased vision. Gonioscopy can localize cyclodialysis clefts and determine their extent; however, this might be difficult in hypotonous eyes with a flat anterior chamber and corneal edema. Thus, using an ophthalmic viscoelastic device and/or pilocarpine drops can improve angle visualization in those eyes [1]. Posterior cyclodialysis cleft with communication between the posterior chamber and suprachoroidal space is difficult to visualize with gonioscopy [13]. Imaging modalities such as UBM and AS-OCT can aid in the diagnosis of cyclodialysis clefts, especially with dynamic imaging to open a cleft during imaging.

Medical therapy is usually the first line of treatment for cyclodialysis clefts, especially small clefts. Cycloplegics are used as they cause ciliary muscle relaxation and aid its contact with the sclera. The role of steroids is controversial; while some clinicians recommend increasing the steroid frequency to increase IOP and decrease ciliary effusion, others advocate decreasing steroids to promote inflammation and cleft closure [9].

In cases of medical management failure, laser techniques may be used to cause local inflammation within the cyclodialysis cleft and promote cleft closure. Argon laser can be applied to the cleft area with the aid of a gonioscopy lens. Additionally, transscleral diode or Nd:YAG lasers can be used to treat cyclodialysis clefts, although these approaches are typically only effective for small clefts [14, 15]. Some reports suggested using diode endolaser photocoagulation to visualize and directly treat clefts [16].

For patients who fail conservative management, surgical treatment of the cyclodialysis is warranted. Surgical repair of the cyclodialysis is recommended in cases of persistent hypotony for 2–3 months [17]. Different surgical techniques have been described to repair cyclodialysis clefts. Cyclopexy includes fixation of the ciliary body to the sclera and can be performed to repair cyclodialysis clefts. External transconjunctival cryotherapy can be used in small clefts [18]. Direct cyclopexy using sutures can be performed through ab-externo or ab-interno approaches. In the ab-externo approach, a partial or full-thickness scleral flap is created to allow direct visualization and suturing of the ciliary body to the sclera. Suturing of the ciliary body can also be performed through an internal approach using the opposite clear corneal incision, as in our report [18]. Success rates of direct cyclopexy were reported to be up to 96%; however, complications such as hemorrhage, retinal detachment, or endophthalmitis can occur [19, 20]. Other surgical techniques to tamponade the detached ciliary body have been proposed. An anterior scleral buckle (3 mm behind the limbus) can be used temporarily. Gas tamponading using intravitreal SF₆ or C₂F₆ with or without pars vitrectomy has also been described in the treatment of cyclodialysis clefts [21]. Other reports recommended using a 3-piece intraocular lens in the sulcus or sulcus-sutured capsular tension ring. These devices may be superior in treating larger clefts; however, there are associated risks of ciliary body injury, erosion, pain, and hemorrhage [22, 23].

Closure of cyclodialysis clefts can lead to a period of elevated IOP in around 60% of cases due to the restoration of aqueous humor production from the ciliary body without complete recovery of trabecular meshwork function [18, 20]. Usually, this phase resolves spontaneously, but medical therapy might be required to temporarily control the IOP as occurred in our patient [18]. In rare cases, incisional glaucoma surgeries are needed to manage the IOP spike [24]. Some reports suggest that in larger clefts, a longer duration is usually required for IOP normalization [25].

Cyclodialysis with resultant hypotony can occur as a complication of IVIs. Although it is a rare complication, it is crucial to suspect this pathology in patients with post-IVI hypotony without evidence of wound leak. Adjunctive imaging techniques (UBM and AS-OCT) are helpful tools to diagnose cyclodialysis clefts. Medical therapy should be attempted initially, with more invasive surgical options reserved for non-resolving cyclodialysis clefts. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material.

This retrospective review of patient data did not require ethical approval in accordance with local/national guidelines. Written informed consent was obtained from the participant for publication of the details of their medical case and any accompanying images.

The authors have no relevant conflicts of interest to disclose with this manuscript.

This study was not supported by any sponsor or funder.

All authors attest that they meet the current ICMJE criteria for authorship. M.M.K.: conceptualization, investigation, methodology, and writing – review and editing. A.M.E.: investigation, methodology, writing – original draft, and writing – review and editing. C.A.D.: writing – original draft and writing – review and editing. R.K.L. and M.S.S.: conceptualization, supervision, project administration, and writing – review and editing.

All data generated or analyzed during this study are included in this article and its online supplementary material. Further inquiries can be directed to the corresponding author.