Cyclodialysis cleft after secondary intraocular lens placement with Yamane technique

Abstract

Purpose:

To report a rare case of cyclodialysis cleft following secondary intraocular lens placement using the Yamane flanged intrascleral haptic fixation technique.

Methods:

Observational case report

Results:

A 74-year-old male with an ocular history of spontaneously dislocated intraocular lens (IOL) and subsequent anterior chamber intraocular lens (ACIOL) placement, presented with monocular diplopia secondary to ACIOL subluxation. The patient underwent explantation of the subluxed ACIOL and placement of a scleral fixated IOL using the Yamane technique. The post-operative course was complicated by persistent hypotony, prompting ultrasound biomicroscopy (UBM) which revealed a cyclodialysis cleft adjacent to one of the externalized IOL haptics. While performing direct cyclopexy, the haptic was discovered in the involved supraciliary space. The cyclodialysis cleft closed with return to physiologic intraocular pressure.

Conclusions:

Cyclodialysis cleft formation is a possible complication of scleral IOL fixation and should be suspected in cases of prolonged post-operative hypotony. Extended longitudinal tracking of the needle and haptic through the supraciliary space may be one mechanism for cyclodialysis cleft formation in the Yamane technique.

Introduction

Scleral fixation is a common approach to placement of an intraocular lens (IOL) when capsular support is not available. Conventional sutured scleral fixation uses non-absorbable polypropylene or Gore-Tex sutures to secure IOL haptics to the sclera within the ciliary sulcus. Sutureless IOL fixation was described by Scharioth et al. in which haptics are seated within two limbus-parallel intrascleral tunnels.¹ Further modifications to the intrascleral haptic fixation technique have used fibrin glue to seal the scleral flaps and conjunctiva.² More recently, the Yamane flanged intrascleral haptic fixation technique has been described; utilizing two thin-walled 30-gauge needles to create scleral tunnels, the IOL haptics are then docked, externalized, and cauterized to form a securing flange.³ This technique has gained popularity for its sutureless, transconjunctival approach with relatively good safety profile and refractive outcomes.⁴ Yamane et al. reported complications including iris capture by the IOL, vitreous hemorrhage, and cystoid macular edema.³ Subsequent studies have also reported elevated intraocular pressure, hypotony, hyphema, reverse pupillary block, exposed haptics, and lens tilt or decentration as potential complications.⁵ We report the clinical course and imaging of cyclodialysis after scleral fixation using the Yamane technique as well as proposed mechanisms for cleft formation.

Case Report

A 74-year-old male initially presented to clinic in 2017 with a spontaneously dislocated intraocular lens (IOL) of the left eye. He had a history of a macular hole repaired in 2004, followed in 2005 by cataract extraction with intraocular lens implantation. Axial length of the left eye was 27.20 mm. He did not have a history of ocular trauma or connective tissue disease. He underwent pars plana vitrectomy, explantation of the dislocated IOL through a superior scleral tunnel incision, and placement of an anterior chamber intraocular lens (ACIOL). Best corrected vision one month after surgery was 20/30.

Two years later, the patient returned with monocular diplopia of the left eye. Visual acuity was 20/30; however the inferior haptic of the ACIOL had migrated through the inferior peripheral iridotomy, causing ACIOL tilt. He underwent explantation of the ACIOL and placement of a scleral fixated CT Lucia 602 (Carl Zeiss Meditec, Dublin, CA) intraocular lens using the Yamane technique. The haptics were externalized through tunneled sclerotomies superotemporally and inferonasally. The lens was noted to be well-positioned at the end of the case with the flanged haptics visible subconjunctivally. At the post-operative week one visit, vision was 20/60, intraocular pressure (IOP) was 5 mmHg, and there was 2+ anterior chamber inflammation. There was no evidence of wound leak or inadvertent filtering bleb, so the hypotony was attributed to decreased ciliary body function due to intraocular inflammation; his prednisolone was increased to 6 times daily. At the post-operative month one visit, inflammation had subsided but IOP remained at 5mm Hg, and the patient had developed hypotony maculopathy with choroidal folds. Gonioscopy revealed focal widening of the ciliary body band superotemporally. Ultrasound biomicroscopy (UBM) confirmed the presence of a cyclodialysis cleft with disinsertion of the iris and ciliary body at the 1:00 position and shallow choroidal effusions 360 degrees (Figure 1A). Scleral thickness overlying this area was measured at 455 microns. Conservative management with topical steroids and cycloplegia was unsuccessful in resolving the cleft, and two months later the patient underwent direct cyclopexy. A superotemporal partial thickness scleral flap was created over the zone where the cyclocdialysis had been identified on UBM extending 3mm posteriorly from limbus. A slit incision was made parallel to the limbus under the scleral flap exposing the ciliary body, and multiple interrupted 10-0 nylon sutures were placed through the slit incorporating ciliary body and sclera with each bite. The scleral flap was then closed over the sutures. The haptic flanges were visible under the conjunctiva prior to surgery; however, the superotemporal haptic was noted to be longitudinally traversing the involved supraciliary space (Figure 1B). Retrospective review of pre-operative UBM images revealed a hyper-echoic focus in the supraciliary space likely representing the IOL haptic (Figure 1C). The cyclodialysis cleft improved after surgery and the patient’s IOP slowly returned to physiologic levels (12-14 mmHg). Repeat UBM four months later showed resolution of the cyclodialysis cleft (Figure 1D). Visual acuity remained 20/50 due to prolonged hypotony maculopathy.

Figure 1.

A) Superotemporal cyclodialysis cleft on ultrasound biomicroscopy (UBM) B) Intraocular lens (IOL) haptic visible in the suprachoroidal space during direct cyclopexy C) IOL haptic within the cyclodialysis cleft on pre-operative UBM D) Resolved cyclodialysis cleft 4 months after direct cyclopexy. Yellow arrow = IOL haptic

Discussion

Cyclodialysis clefts occur most commonly due to blunt ocular trauma, but have also been reported following various intraocular surgeries.⁶ The incidence of iatrogenic cyclodialysis cleft is unknown. Post-operative hypotony is not uncommon following incisional surgery, and can be due to wound leaks, retinal detachment, inadvertent or intentional filtering blebs, decreased ciliary body function, and prostaglandin-mediated increased uveoscleral outflow. Given the potential for spontaneous resolution of cyclodialysis clefts, it is possible that a significant number of cases go unrecognized. Post-operative hypotony in the absence of the above findings, as was the case with our patient, should raise suspicion for cyclodialysis and prompt further investigation. Gonioscopy, ultrasound biomicroscopy, and anterior segment optical coherence tomography are excellent modalities for the detection and characterization of cyclodialysis clefts.⁶

The flanged intrascleral IOL fixation with double-needle technique, first described by Yamane et al. in 2017, offers a fast and secure approach to IOL fixation in the absence of capsular support. In theory the technique may be less prone to endothelial decompensation and uveitis-glaucoma-hyphema syndrome, complications that can be associated with anterior chamber and iris-fixated IOLs, although prospective comparative studies are lacking.^8,9 However, as the technique is more widely adopted, novel complications will continue to emerge. Here we have reported the clinical course and imaging findings of a patient with cyclodialysis cleft formation after sutureless intrascleral IOL fixation via the Yamane technique.

Prior surveys of Yamane technique outcomes have reported post-operative hypotony, but no cause is specified, and most cases are transient.⁵ We have encountered two previous articles reporting cyclodialysis cleft after Yamane technique. The first, a retrospective case series of 47 eyes, mentions one case of cyclodialysis-associated hypotony that was treated with laser, but no imaging or follow-up data was provided.¹⁰ The second was a small case series that detailed the clinical course and management of two patients who developed cyclodialysis cleft following Yamane technique.¹¹ Similar to our patient, both cases had cleft formation in the axis of IOL fixation.

Cyclodialysis cleft formation during Yamane technique could be due to a number of mechanisms including traumatic sclerotomy creation, posterior forces on the iris root during IOL placement and haptic docking, contralateral forces during haptic externalization and IOL centering, or flange migration into the suprachoroidal space. In our patient, the long traverse of the haptic through the supraciliary space, as discovered during cyclopexy and supported by UBM findings, may suggest a potential mechanism for ciliary body injury. The Yamane technique relies on “blind” 2mm partial-thickness scleral passes with a needle prior to re-directing and penetrating into the posterior chamber (Figure 2A). If the needle instead traverses 2mm within the supraciliary space, subsequent needle rotation into the eye applies torque to the ciliary body instead of the sclera (Figure 2B). This scenario may be more common in patients with axial myopia or thin sclera. We propose that this mechanism contributed to cyclodialysis cleft formation in our patient.

Figure 2.

A) Ideal partial-thickness needle sclerostomy track prior to re-directing into the posterior chamber B) Possible mechanism for cyclodialysis in this patient, with longitudinal tracking through the supraciliary space instead of sclera prior to re-directing into the posterior chamber. Grey = needle; Yellow = sclera; Red = ciliary body; Blue = IOL haptic/bulb

Medical management of cyclodialysis clefts involves topical cycloplegia and steroids. Gonioscopy-guided argon laser photocoagulation to the sclera and ciliary body in the area of the cleft can promote local inflammation and cleft closure. This approach may be most successful in cases with less than 2 clock hours of cyclodialysis.⁷ Transscleral diode laser photocoagulation, transscleral diathermy, and cryotherapy have also been used to facilitate cleft closure. Surgical options include direct cyclopexy, sulcus-sutured capsular tension rings, and gas endotamponade in conjunction with cryotherapy.⁶ Direct comparisons of these techniques are not common, but some suggest that the closure rate for surgical repair is higher than that of laser treatment.⁷ In this case, the presence of the haptic in the suprachoroidal space may have prevented spontaneous resolution and necessitated suturing to seal the defect.

Cyclodialysis cleft formation is a rare but possible complication of the flanged intrascleral haptic fixation technique and may occur with inadvertent needle or haptic introduction into the supraciliary space during sclerotomy creation. There is inadequate data in the literature on the timing and methods of repair for a cyclodialysis caused by a haptic and if leaving the haptic in place may prolong recovery after cyclodialysis repair. Eyes with thin sclera, axial myopia, and prior surgical trauma may create additional challenges. UBM can be a useful diagnostic tool in patients with unexplained prolonged post-operative hypotony. If conservative management fails, surgical repair may facilitate cleft closure.