Aqueous Humor Dynamics in a Patient With Chronic Hypotony, Cyclodialysis Clefts, and Ciliochoroidal Detachment

Castillo, Francisco

Aqueous Humor Dynamics in a Patient With Chronic Hypotony, Cyclodialysis Clefts, and Ciliochoroidal Detachment

Friday, April 25, 2014

KIOSKS (Boston Convention and Exhibition Center)

Francisco Castillo, MD, Mayo Clinic Rochester, Rochester, MN, USA

Sejal Amin, MD Rochester, MN, USA

Arthur J Sit, SM, MD, Mayo Clinic, Rochester, MN, USA

Raymond Iezzi, MD, MS, Mayo Clinic, Rochester, MN, USA

Jay W. McLaren, PhD, Mayo Clinic, Rochester, Minnesota, USA

Cheryl L. Khanna, MD, Mayo Clinic, Rochester, MN, USA

Narrative Responses:

Purpose
To describe the aqueous humor dynamics and pathophysiology of hypotony in a patient with traumatic circumferential cyclodialysis clefts, hypotony, choroidal folds, and hypotony maculopathy. To describe a non-surgical option for management of cyclodialysis clefts.

Methods
Circumferential cyclodialysis secondary to a paintball injury in a 17-year old patient was confirmed by slitlamp biomicroscopy, gonioscopy, UBM, and acOCT. The intraocular pressure was 4 mmHg and failed to improve with topical corticosteroids, cycloplegics, and NSAIDs. Treatment of the areas of visualized cyclodialysis with an Argon laser also failed to close the cleft. Hoping to avoid a surgical intervention in a young patient, oral Prednisone 60 mg daily was administered. Aqueous humor flow was measured by fluorescein clearance immediately after confirmation of the cyclodialysis before treatment, and after confirmation of the cyclodialysis cleft resolution.

Results
After confirmation of a cyclodialysis cleft and ciliochoroidal detachment, aqueous humor flow rate estimated by fluorescein clearance was 7 µl/min, considerably elevated from the 2.2 – 3.1 µl/min in normal eyes⁴. The increased estimated rate of aqueous flow was likely an artifact of accelerated loss of fluorescein through the cleft. Seven days after oral corticosteroids and 4 months after the initial injury, the cleft closed with subsequent improvement in vision and decreased macular edema. The patient’s IOP increased to 21 mmHg. Aqueous humor flow rate re-measured after resolution of the cleft was 3.3 µl/min.

Conclusion
Fluorophotometry in a patient with a large traumatic cyclodialysis cleft over-estimates aqueous humor flow and suggests that hypotony is secondary to loss of aqueous humor through the cleft. Oral steroids are a potential non-surgical option in these patients, as evident by the normalization of pressure and estimates of aqueous flow.