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Case report

Cyclodialysis cleft with late hypotony maculopathy after inadvertent cannula detachment during cataract surgery

Kahawita, Shyalle MB BS*; Cugati, Sudha PhD, FRANZCO; Casson, Robert DPhil, FRANZCO

Author Information
Journal of Cataract & Refractive Surgery: May 2015 - Volume 41 - Issue 5 - p 1107-1108
doi: 10.1016/j.jcrs.2015.04.002
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Abstract

Inadvertent cannula release during various stages of cataract surgery has been reported.1,2 Complications resulting from cannula release are usually described in the immediate postoperative period. We present a case in which cannula release occurred during surgery but hypotony was identified several years later.

Case report

A 69-year-old woman had cataract surgery with intraocular lens (IOL) implantation using a temporal clear corneal approach in the right eye. The procedure was uneventful until wound hydration. During stromal hydration of the temporal wound, the cannula of the Luer-locked syringe “shot” off. This resulted in bleeding from the peripheral nasal iris, which was cleared with irrigation/aspiration. The IOL and the posterior segment were unaffected.

On postoperative day 1, Snellen uncorrected distance visual acuity (UDVA) in the right eye was 6/24. There was a 1.0 mm hyphema, and the intraocular pressure (IOP) was 8 mm Hg. The patient was managed conservatively, and after 1 month, the UDVA in the right eye was 6/6 and the IOP was 8 mm Hg.

The patient was seen for a routine diabetic check 34 months after cataract surgery. The UDVA in the right eye was 6/24, the IOP was 3 mm Hg, and posterior capsule opacification (PCO) was noted. Because the decreased visual acuity was thought to be due to the PCO, a neodymium:YAG (Nd:YAG) capsulotomy was performed.

After the Nd:YAG capsulotomy, the UDVA in the right eye was 6/12 and the IOP was 2 mm Hg. Gonioscopy revealed a cyclodialysis cleft in the nasal angle (Figure 1). Fundus examination revealed choroidal folds at the macula, demonstrable on optical coherence tomography (OCT) (Figure 2). Conservative treatment with atropine failed to close the cleft so the cleft was treated with slitlamp-delivered goniophotocoagulation. The IOP subsequently increased to 6 mm Hg, and the UDVA improved to 6/9 and remained stable.

Figure 1
Figure 1:
Gonioscopy showing the cyclodialysis cleft at the nasal angle.
Figure 2
Figure 2:
A: Fundus photograph of the right eye showing choroidal folds and macular hypotony. B: Optical coherence tomography showing wrinkling of the retina and choroid.

Discussion

A cyclodialysis cleft results from separation of the ciliary body complex from the scleral spur, allowing aqueous to flow from the anterior chamber to the suprachoroidal space.3 Typically, the presence of a cyclodialysis cleft can be suspected if there is a history of trauma, cataract, glaucoma, or retinal detachment repair surgery. Examination findings include low IOP, a shallow anterior chamber, retinal or choroidal folds, induced hyperopia, and decreased vision.

Identifying a cyclodialysis cleft can be difficult, especially if the anterior chamber is shallow and the eye is soft. Apart from direct visualization with gonioscopy, ultrasound biomicroscopy and anterior segment OCT have been used to detect a cleft.3,4 Ultrasound biomicroscopy produces high-resolution images of the anterior chamber, angle, and ciliary body. Anterior segment OCT can analyze the angle, but the ciliary body and suprachoroidal space might not be well visualized.

Management of a cyclodialysis cleft includes medical, laser, or surgical techniques. For a cleft smaller than 4 hours, medical treatment with a topical cycloplegic agent, such as atropine 1.0% for 6 to 8 weeks, can be used to promote scarring. If not successful, the argon laser can be used to induce inflammation.3–5 Other techniques for small clefts include transscleral diathermy and transconjunctival cryotherapy. Larger clefts that are not responsive to conservative medical or laser therapy may be closed by direct cyclopexy through a partial-thickness limbal scleral flap. The use of a capsular tension ring in the sulcus and the haptics of a poly(methyl methacrylate) IOL to compress the cleft against the sclera has been described.3,4

There are multiple case reports of inadvertent cannula release with both the Luer lock and nonthreaded syringes.1,2,6 To our knowledge, our case is the first report of late hypotony maculopathy as a result of inadvertent cannula release during cataract surgery. In our patient, it is almost certain that the inadvertent cannula release caused the cyclodialysis cleft, resulting in late hypotony maculopathy. The case serves as a reminder of the dangers of inadvertent cannula release and the possible long-term consequences.

References

1. Buys YM, Firat M, Brent MH., 2009. Posterior capsular rupture secondary to viscoelastic cannula and luer-lock release during phacotrabeculectomy [letter], Can J Ophthalmol, 44, 102-103.
2. Osher RH. Iris damage by inadvertent cannula injection. J Cataract Refract Surg. 2007;33:339-341.
3. Ioannidis AS, Barton K. Cyclodialysis cleft: causes and repair. Curr Opin Ophthalmol. 2010;21:150-154.
4. Aminlari A, Callahan CE. Medical, laser, and surgical management of inadvertent cyclodialysis cleft with hypotony. Arch Ophthalmol. 122, 2004, p. 399-404, Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/9920/ecr0304-5-1.pdf. Accessed January 31, 2015.
5. Ioannidis AS, Bunce C, Barton K. The evaluation and surgical management of cyclodialysis clefts that have failed to respond to conservative management. Br J Ophthalmol. 98, 2014, p. 544-549, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963549/pdf/bjophthalmol-2013-303559.pdf. Accessed January 31, 2015.
6. Rumelt S, Kassif Y, Koropov M, Landa E, Marzuk F, Segal ZI, Vinerovsky A, Rehany U. The spectrum of iatrogenic intraocular injuries caused by inadvertent cannula release during anterior segment surgery. Arch Ophthalmol. 125, 2007, p. 889-892, Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/9990/ecs70006_889_892.pdf. Accessed January 31, 2015.
© 2015 by Lippincott Williams & Wilkins, Inc.