Challenging Diagnosis And Repair Of An Extensive Cyclodialysis Cleft

Cyclodialysis cleft (CDC) is a rare yet severe ocular issue, resulting from a detachment between the ciliary body and the scleral spur. Typically caused by blunt trauma or iatrogenic injuries, CDC leads to reduced aqueous production and increased outflow, often resulting in hypotony and potential maculopathy. Diagnosis is challenging due to low eye tonicity and associated comorbidities. Our case details a young patient with an 8-clock-hour CDC from blunt trauma, discussing the diagnostic process, surgical technique, and postoperative outcomes. 

A 25-year-old man presented with ocular pain, visual impairment, eyelid hematoma, subconjunctival hemorrhage, and Berlin's edema following blunt trauma to the right eye. Initial conservative treatment with medications was converted to surgery due to hypotony-induced maculopathy.

Ultrasound biomicroscopy (UBM) and gonioscopy revealed extensive supraciliary and suprachoroidal fluid and a CDC whose dimensions were inconclusive. However, consequent intraoperative UBM provided precise real-time anatomical evidence of an extensive CDC extending 8 clock hours and mandating closure with a direct cycloplexy approach. Layered scleral dissection and direct suturing of the ciliary body to the sclera was performed with 8-0 nylon sutures, resulting in CDC resolution, supraciliary and suprachoroidal fluid absorption, visual acuity improvement, and intraocular pressure stabilization.

This case highlights the innovative use of intraoperative UBM as a critical tool, offering real-time guidance in managing an extensive CDC. The successful closure and improved visual outcomes in this case further validate the efficacy of direct cycloplexy for extensive CDCs.