Transient choroidal detachment after ultrasonic circular cyclocoagulation

Abstract

Two patients with refractory glaucoma followed in our ophthalmology department registered progression on left eyes (OS) despite best practice. Best corrected visual acuity (BCVA) was 9/10 and 8/10 and intraocular pressure (IOP) was above 20 mm Hg while under maximal hypotensive therapy. The procedure was performed under retrobulbar anaesthesia with second-generation EyeOp1probes. In follow-up, OS were hypotonic with registered IOP ≤5 mm Hg and revealed a 3/10 BCVA. The funduscopy showed one temporal and superior and another nasal and temporal choroidal detachments. The patients started oral steroids and interrupted all ocular hypotensive medication. After therapy, patients returned with normal rising OS IOPs and with totally reapplied choroids, accompanied by normalised BCVA. These two cases are proof of the possibility of transient choroidal detachment after a ultrasonic circular cyclocoagulation. While a very rare major vision-threatening complication, every ophthalmologist should remind it when sudden BCVA reductions occur after this procedure.

Background

These two cases are important, even if rare, because they are possible, and their correct diagnosis and treatment might make the difference between achieving the recovery to optimised visual acuity and remaining with sequential loss of visual acuity after a ultrasonic circular cyclocoagulation (UCCC) procedure.

Case presentation

The UCCC is a new therapeutic procedure for uncontrolled glaucoma disease, being presently classified as non-invasive glaucoma procedure. This procedure targets the ciliary body, induces its necrosis and creates a uveoscleral pathway through the application of high-intensity focused ultrasound. Despite being an effective and safe procedure, there have still been described some complications.^{1 2}

Regarding effectiveness, the most recent studies show a 1-year success rate of 85% with average reductions from preoperative levels of intraocular pressure (IOP) of 27.8% (first procedure), 20.3% (second procedure) and 34% (third procedure).¹

While the majority of the complications are minor and not vision-threatening complications, there have been cases of transient macular oedema (1/28) and of transient choroidal detachment with hypotony (1/28).^1–5 Comparatively to the already available cyclocoagulation procedures, UCCC has shown less severe complications, as shown in tables 1–4.

Table 1.

List of ocular complications posterior to ultrasonic circular cyclocoagulation procedures from Denis et a l ³

Ocular complications	N	Incidence
Conjunctival hyperaemia	16	57.14%
Superficial punctate keratitis	11	39.29%
Corneal oedema	2	7.14%
Ocular pain	2	7.14%
Anterior chamber reaction	7	25.00%
Transient hypotony, choroidal detachment	1	3.57%
Transient macular oedema	1	3.57%
Phthisis bulbi	0	0.00%
Cataract	0	0.00%
Intravitreous haemorrhage	0	0.00%
Loss of visual acuity (>2 lines)	0	0.00%

The bold values in tables are related to the epidemiologic data (incidence values) of the clinical cases published.

Table 2.

List of ocular complications posterior to ultrasonic circular cyclocoagulation, adapted from Mastropasqua et al ⁴

Ocular complications		Incidence
Mild	Conjunctival hyperaemia	37.5%–75%
	Subconjuncitval haemorrhage	4%–16.6%
	Superficial punctate keratitis	10.7%–40%
	Anterior chamber reaction	16.6%–40%
	Intraocular pressure spikes	6.6%–20.8%
	Focal scleral thinning	3.3%
Severe	Transient visual acuity decrease	10.7%
	Transient hypotony	1.6%–5 %
	Transient macular oedema	3.3%–3.6%
	Corneal oedema	7.1%–8.3%
	Corneal ulceration	8.3%–16.6%

The bold values in tables are related to the epidemiologic data (incidence values) of the clinical cases published.

Table 3.

List of ocular complications posterior to cyclocriotherapy, adapted from Mastropasqua et al ⁴

Ocular complications		Incidence
Mild	Anterior chamber flare/uveitis	17.6%–100%
	Hyphema	4%–17.6%
	Sterile hypopyon	1.5%
	Lens dislocation	1 case
Severe	Visual acuity loss	5.3%–58%
	Visual acuity decrease	32.3%–45.1%
	Hypotony	3.33%–32%
	Phthisis bulbi	3.3%–40%
	Choroidal detachment	2%
	Retinal detachment	1.6%

The bold values in tables are related to the epidemiologic data (incidence values) of the clinical cases published.

Table 4.

List of ocular complications posterior to transcleral contact cyclophotocoagulation, adapted from Mastropasqua et al ⁴

Ocular complications		Incidence
Mild	Anterior chamber flare/uveitis	9%–28%
	Hyphema	0%–2%
	Pain	9%–21%
	Pupillary changes	0.8%–50%
Severe	Visual acuity loss	8.8%–47%
	Visual acuity decrease	38.5%–62.5%
	Capital hypotony	0%–26%
	Phthisis bulbi	0%–10.7%
	Retinal detachment	1%

Clinical case 1

A 72-year-old patient with diabetes mellitus type 2 and glaucoma disease has been followed in Hospital Espírito Santo de Évora (HESE), ophthalmology department for 10 years, with registered left eye (OS) progression of the disease despite best clinical practice (having already been submitted to a trabeculectomy in OS in 2009 and to a Xen45 implant procedure in the right eye (OD) in 2017). The baseline best corrected visual acuity (BCVA) was of 9/10 (0.046 logMAR). The patient presented an OS IOP of 20 mm Hg while under maximal topical medical therapy (brimonidine 2% twice daily, dorzolamide 2%/timolol 0.5% two times a day, travoprost 0.004% every day). Despite spectral-domain ocular coherence tomography (SD-OCT) pointing to structural disease stabilisation (disc–cup ratio, retinal nerve fibre layer and ganglionar cell complex stable values), the OS showed clear progression of the disease on visual field examination, with decrease in visual field index and increase in pattern-SD.

Clinical case 2

A 74-year-old patient with glaucoma disease has been followed in Hospital Espírito Santo de Évora (HESE), ophthalmology department for 8 years, with registered OS progression of the disease despite best clinical practice (having already been submitted to a trabeculectomy OS in 2011). The baseline BCVA was of 8/10 (0.1 logMAR). The patient presented an OS IOP of 21 mm Hg while under maximal topical medical therapy (clonidine 0.25% two times a day, bimatoprost 0.03%/timolol 0.5% every day, brinzolamide 1% two times a day). Despite SD-OCT pointing to structural disease stabilisation (disc–cup ratio, retinal nerve fibre layer and ganglionar cell complex stable values), the fluctuations of IOP in above target levels demanded further treatment.

Treatment

This publication was conducted not only in accordance with the Helsinki Declaration but also in accordance with the European Union’s Good Clinical Practice Directive (Directive 2005/28/EC of 8 April 2005 of the European Parliament).

The patients were examined with Goldmann applanation tonometry for IOP measuring, with a Humphrey Field Analyser (Humphrey Field Analyser II-I series, Carl Zeiss Meditec) for visual field evaluation and with a SD-OCT for structural evaluation (Cirrus OCT 500, Carl Zeiss Meditec).

The patient accepted to be submitted to UCCC procedures. The UCCC procedures were performed in the operatory room with second-generation probes EyeOP1 (figure 1) and with the standard parameters (six sectors with an average of 45% of the entire ciliary body circumference targeted, 21 MHz of frequency, 2–3 W of intensity and with a duration of 8 s in each sector), under retrobulbar anaesthesia.

Figure 1.

Picture of EyeOp1 probe provided by EyeTechCare.

Outcome and follow-up

Clinical case 1

After the procedure, the patient returned home under the same maximal medical therapy and started therapy with topical fluorometholone 0.1% three times a day.

At D1 postprocedure, the OS showed difuse light conjunctival hyperaemia with mild inferior keratitis.

At D10 postprocedure, the OS showed difuse light conjunctival hyperemia, with an IOP value of 2 mm Hg with a diminutive and almost imperceptible lesion consistent with a very small choroidal detachment, after funduscopy. The patient interrupted brimonidine 2% two times a day and travoprost 0.004% every day and remained with topical dorzolamide 2%/timolol 0.5% two times a day and topical fluorometholone 0.1% three times a day.

At D16 postprocedure, the patient came to the clinic for the regular follow-up. The BCVA suffered a sudden dramatic decrease to 3/10 (0.523 logMAR). The OS was hypotonic with a registered IOP of 2 mm Hg. After dilation, the funduscopy showed a temporal and superior choroidal detachment. On this diagnosis, the patient started medical therapy with topical dexamethasone 1% every 4 hours and atropine 10% three times a day and interrupted all remaining ocular hypotensive medication. After ultrasound confirmation of the diagnosis (figure 2), the patient returned at D21 with the same value of IOP and with the same extension of the choroidal detachment and started oral methylprednisolone 16 mg every day.

Figure 2.

OS B-mode ultrasound at D16 postprocedure with choroidal detachment superiorly in clinical case 1.

At D42 postprocedure, the patient returned with an OS IOP value of 16 mm Hg and with a totally reapplied choroid, having started the corticosteroid (oral and topical) and atropine taperings. At D58 postprocedure, the patient returned to the clinic, without any current medication on OS and registered an OS BCVA of 7/10 (0.155 logMAR), an OS IOP of 16 mm Hg, a totally applied choroid and a stable visual field examination.

Presently, the patient’s OS remains without any permanent retinal damage and the IOP also remains controlled (IOP <21 mm Hg).

It remains unclear whether the previously performed trabeculectomy had any part to play in the formation of the choroidal detachment, as it seems too much of a coincidence that the detachment happened in the sector where the filtering surgery was performed. Having said that, the several previous studies, which included significant rates of patients already submitted to filtering surgery (24.5%–100%), did not show a higher likelihood in this subgroup of patients.^{1–3 5}

Nonetheless, the question remains, was the location only a coincidence?

Clinical case 2

After the procedure, the patient returned home under the same maximal medical therapy and started therapy with topical fluorometholone 0.1% three times a day.

At D1 postprocedure, the OS showed difuse light conjunctival hyperaemia with superficial inferior keratitis and with anterior chamber reaction (Tyndall sign +/++) and with an IOP value of 22 mm Hg.

At D9 postprocedure, the patient referred blurry vision complaints and the OS showed a clear cornea with some corneal Descemet folds, with an IOP value of 7 mm Hg. There were no other changes visible at the time. The patient had inadvertently stopped all hypotensive medication in OS and was allowed to remain so, due to his low IOP value.

At D33 postprocedure, the patient came to the clinic for the regular follow-up. The BCVA suffered a sudden dramatic decrease to 3/10 (0.523 logMAR). The OS was hypotonic with a registered IOP of 5 mm Hg. After dilation, the funduscopy showed a temporal and nasal choroidal detachment of small extension. On this diagnosis, the patient started medical therapy with oral methylprednisolone 12 mg three times a day. The ultrasound examination at D65 showed a total reapplied choroid already without any documented signs of the previous choroidal detachment (figure 3).

Figure 3.

OS B-mode ultrasound at D65 postprocedure without clear imagiological evidence of choroidal detachment in clinical case 2.

The patient returned at D240 with a BCVA of 8/10 (0.1 logMAR), with an IOP of 11 mm Hg under hypotensive medication (bimatoprost 0.03%/timolol 0.5% every day, brinzolamide 1% two times a day) and maintained a totally reapplied choroid.

Currently, patient’s OS remains without any permanent retinal damage and the IOP also remains controlled (IOP <21 mm Hg).

Discussion

While the UCCC procedure has been shown to be effective and safe in previous studies, there are still some complications which arise from this procedure, mainly minor. However, these constitute some of the rare episodes of transient hypotony and transient choroidal detachment posterior to a UCCC procedure. Thus, it remains important for every physician to be aware of this possibility when confronted with sudden BCVA reduction after a UCCC procedure.

Learning points.

• The ultrasonic circular cyclocoagulation (UCCC) procedure has proven to be effective in lowering intraocular pressure values in patients with refractory glaucoma.

• Comparatively to other cyclodestruction procedures, the UCCC presents the highest safety profile with lesser rates of major and minor complications.

• However, UCCC is still not devoid of risks, and transient hypotony and choroidal detachment are among the major complications possible and should be regarded as remembered whenever a patient suffers from a sudden best corrected visual acuity reduction following a UCCC procedure.