Cause Of Hypotony Research Articles

Early Drainage of Suprachoroidal Hemorrhage Combined with Surgical Correction of Hypotony after Trabeculectomy.

Delayed suprachoroidal hemorrhage (DSCH) is a vision-threatening complication of intraocular surgeries with a higher prevalence in postglaucoma filtering surgeries. Through these case series of trabeculectomy complicated with DSCH, we aim to emphasize that correction of hypotony (inciting factor) is fundamental for complete resolution and prevention of recurrence. All three glaucoma patients underwent trabeculectomy surgery followed by DSCH on postoperative day 1. Drainage of DSCH using a 23 gauge trocar cannula within 48 hours of onset was performed along with exploration for the cause of hypotony. All three patients had satisfactory visual and anatomical outcomes. Early drainage using 23 gauge trocar cannulas gives good results in DSCH. The cause of hypotony must simultaneously be corrected during the drainage of DSCH. Preventive measures against hypotony should be taken while doing glaucoma filtering surgery. Surgical exploration for the cause of hypotony must simultaneously be performed during drainage of DSCH. Primary preventive measures against hypotony and bleeding during glaucoma filtering surgeries, like the use of releasable sutures, viscoelastic in the anterior chamber, and discontinuation of anticoagulants, can be done. Early drainage using trocar cannulas gives satisfactory results in DSCH postglaucoma surgeries. Beri N, Verma S, Bukke AN, et al. Early Drainage of Suprachoroidal Hemorrhage Combined with Surgical Correction of Hypotony after Trabeculectomy. J Curr Glaucoma Pract 2024;18(1):23-27.

Intra-operative scleral rupture during 23 gauge pars plana vitrectomy: a case report

BackgroundUse of perfluorocarbon liquid (PFCL) has been increasingly growing as an adjuvant in vitreo-retina surgeries. Some commonly encountered complications with its use include subretinal migration, formation of sticky silicone oil or retained PFCL in vitreous cavity and anterior chamber. Scleral rupture during PFCL injection has a rare occurrence. We report an unexpected event of scleral rupture during PFCL injection and discuss the management challenges faced by the surgeon.Case presentationA 66 year indo-aryan male was undergoing pars-plana vitrectomy (PPV) with diagnosis of subtotal rhegmatogenous retinal detachment (RD) with Proliferative Vitreo-retonipathy (PVR)-B. After near total vitrectomy PFCL was being injected and then there was sudden poor visualization of fundus with development of bullous RD and globe hypotony. The surgeon was not able to figure out the cause of hypotony and air was switched on in the infusion cannula. This further complicated the situation resulting in migration of air in the anterior chamber, posterior dislocation of intraocular lens complex, 180° inferior retinal dialysis and ballooning of the conjunctiva which gave a clue of probable scleral rupture. Conjunctival peritomy was performed superiorly and scleral defect was noted. Intraocular tissue incarceration and air leak was visible from the wound. This confirmed scleral rupture during PFCL injection. Repositioning of incarcerated retina was not possible and retinectomy was performed followed by repair of scleral rupture with lots of difficulty in a vitrectomised eye.ConclusionPFCL injection, a crucial step of vitreoretina surgery, should be performed slowly with extreme caution maintaining an optimal intraocular pressure to prevent devastating complications like scleral rupture.

Management of posttraumatic ocular hypotony

Die Bulbushypotonie nach Trauma (3 % nach Bulbuskontusion, 50–74 % nach offener Augenverletzung) kann schwere sekundäre Schäden des Bulbus zur Folge haben. Neben Hornhautfalten, Ziliarkörper- und Aderhautabhebung, Stauungspapille e vacuo und Makulasternfalten kann die Schrumpfung des Auges zu einer erheblichen Visusminderung führen. Konsekutiv kann das kontralaterale Auge mit einer okulären Hypertension reagieren. Die Ursache der Hypotonie muss diagnostiziert und kausal behandelt werden. Wenn mehr als 210 Grad des Ziliarkörpers verbleiben, ist ein Bulbuserhalt möglich. Häufige Ursache der posttraumatischen Hypotonie ist eine Zyklodialyse. Kleinere Zyklodialysespalten verschließen sich unter Zykloplegie, größere werden chirurgisch versorgt. Die Zyklopexie kann mit einer primären Wundversorgung oder auch einer Pol-zu-Pol-Chirurgie kombiniert werden. Alternativ sind bei persistierender Hypotonia bulbi eine Silikonölendotamponade bzw. eine Okklusion des Schlemm-Kanals möglich. Die posttraumatische Bulbushypotonie ist komplex und bedarf einer exakten Diagnostik, um ihre Ursachen differenziert und gezielt behandeln zu können.

Post trabeculectomy situations: Hypotony

Hypotony, characterized by a low intraocular pressure <6.5 mm Hg or <5 mm Hg with possible clinical complications, can lead to dreaded complications, posttrabeculectomy. It leads to a breakdown of blood-aqueous barrier, leading to an inflammatory cascade, scarring, and bleb failure, in the long term. It also predisposes to blebitis and other hypotony-related complications. Identifying the cause of hypotony, such as bleb leak or overfiltration, is vital to addressing the underlying cause. It can be managed conservatively with pressure patching, and medically with steroids or cycloplegics, or would require surgical bleb revision, depending on the cause and extend of underlying damage. In this article, we review the definition, pathophysiology, risk factors for hypotony, and posttrabeculectomy and identify the various possibilities, and their respective management strategies.

Use of trypan blue as an aqueous tracer dye to investigate hypotony where cyclodialysis cleft is suspected.

A new method to help diagnose suspected cyclodialysis clefts. To study the use of trypan blue stained aqueous flow patterns in diagnosing causes of hypotony where cyclodialysis clefts were suspected. A case series in a tertiary care centre. Ten subjects presenting with persistent hypotony and retinal changes. Trypan blue was injected into the anterior chamber. The pattern of dye flow in the anterior chamber was categorized. Intraocular pressure prior to surgery was recorded. All seven subjects with cyclodialysis clefts had a preferential flow to the cleft region. Two hypotonous subjects post trabeculectomy had rapid (5 seconds) and extensive lymphatic staining (6 o'clock hours extent) without visible bleb formation. Preferential flow of dye to the limbus is a reliable sign of cyclodialysis cleft and helps localize cleft extent. A new cause of hypotony, "lymphatic overdrain," is identified.

English

Presenting here the outcome of cataract surgery in a 40yr old male patient diagnosed with mature cataract with ocular hypotony. Patient was investigated and all the possible causes of hypotony were ruled out. This was followed by an uneventful cataract surgery with a good visual outcome and normal IOP.

Surgical Repair of Cyclodialysis Cleft

Cyclodialysis cleft is separation of meridonal ciliary muscle fibers from the scleral spur, thereby creating an additional drainage pathway of aqueous humor into the suprachoroidal space.1-4 This new drainage pathway leads to increase in uveoscleral outflow and may result in chronic ocular hypotony.5 The hypotony may also be due to decreased aqueous production.6 In past, creating an iatrogenic cyclodialysis cleft was used as one of the surgical option for the management of aphakic glaucoma. Cyclodialysis mostly occurs inadvertently during anterior segment surgery or due to blunt ocular trauma.2,7 The magnitude of the hypotony due to cyclodialysis cleft may not be proportional to the size of the cleft.5 As a result of ocular hypotony, patient may develop choroidal effusion, cystoid macular edema, optic nerve edema, engorgement and stasis of retinal veins, retinal folds, shallow anterior chamber, and cataract. Cystoid macular edema is one of the major contributing factor for visual loss due to hypotony caused by cyclodialysis cleft. If hypotony remains undetected and untreated for long time, visual loss may become permanent. Ocular hypotony itself is the most frequent cause of ciliochoroidal detachment following cataract extraction. Therefore, prior to considering cyclodialysis cleft as a cause of hypotony, other causes like wound leak, retinal detachment, chronic inflammation, and anterior segment ischemia should be ruled out. A careful gonioscopic examination of the anterior chamber angle is the key to the diagnosis of iatrogenic or traumatic cyclodialysis cleft. Sometimes it is difficult to see the cleft itself, as it is often small and obscured by a narrowed anterior chamber angle. A shallow chamber generally is caused by diffuse choroidal effusion due to hypotony that leads to forward displacement of the lens iris diaphragm. It has been suggested that anterior chamber deepening by the injection of a viscoelastic agent into the anterior chamber may facilitate visualization of the cleft.8 High-resolution ultrasound biomicroscopy (UBM) is a good tool to diagnose and provide detailed information about the extent and location of a cyclodialysis cleft.9-11 UBM allows imaging of a cyclodialysis cleft along its entire longitudinal and circumferential extent, with an accurate assessment of its location and size, regardless of gonioscopic visibility or patent cleft aperture.10,11 While gonioscopy allows evaluation only from the anterior face of the ciliary cleft, UBM provides cross sectional information of the iridocorneal angle. Once the diagnosis of cyclodialysis is made, medical treatment consisting of topical 1% atropine, 2 to 3 times daily should be attempted at-least for 6-8 weeks. Miotics and corticosteroids should be avoided. If the cleft is small in size (< 1⁄2 clock hour) or no significant structural or functional abnormalities secondary to hypotony is seen, then, wait and watch along with medical treatment may be the best mode of action. In small clefts, Argon laser therapy for repair of cyclodialysis can be tried. Various treatment options to close the cleft with laser has been described.3,12-17 It is assumed that, following laser treatment, edema of the choroid closes the cleft and blocks aqueous flow into the suprachoroidal space or perhaps the inflammation produced by laser treatment plays a role in altering the aqueous humor composition, thereby obstructing the drainage.13 Other surgical options includes external transconjunctival cryotherapy at the presumed location of a cyclodialysis cleft, direct cyclopexy, ciliochoroidal diathermy, anterior scleral buckling, or vitreoretinal procedures.18-24 We usually reserve surgical intervention for those cases that do not respond to medical treatment. We prefer direct surgical cyclopexy (Cleft closure) to other surgical options.

Anterior segment inflammation and hypotony after posterior segment surgery

Recent advances in the instrumentation and surgical techniques for posterior segment surgery permit better anatomic and functional outcomes. Nevertheless, these procedures may be associated with complications involving the anterior segment, including postoperative inflammation and hypotony. One must differentiate infectious from noninfectious inflammation to initiate appropriate therapy promptly. Hypotony is a frustrating problem because it is difficult to reverse. The exclusion of eyes with other known causes of hypotony is important before establishing the putative mechanism of tractional ciliary body detachment caused by epiciliary proliferative tissue.

A Simple Treatment for Chronic Postoperative Hypotony of Unknown Etiology: The Injection of Balanced Salt Solution into the Anterior Chamber

Postoperative hypotony is not rare. When it occurs, effective treatment must be initiated to avoid secondary complications. We report two cases of postoperative hypotony that have been treated successfully with a single injection of balanced salt solution (BSS) into the anterior chamber. One patient developed hypotony three months after combined cataract surgery and trabeculectomy with the use of Mitomycin C (MMC). The cause of hypotony remained unknown. Leakage, hyperfiltration, cyclodialysis, and other possible causes had been excluded. With a single injection of BSS into the anterior chamber the long-standing hypotony was successfully managed. A second patient with hypotony after pars plana vitrectomy was also treated successfully with an injection of BSS into the anterior chamber. We conclude that an injection of BSS into the anterior chamber is an inexpensive and efficacious remedy for postoperative hypotony of unknown etiology.

Intraocular hypotony: use of ultrasound biomicroscopy (UBM) for differential diagnosis and its schematic representation

To determine the use of high-frequency ultrasound biomicroscopy (UBM) in the assessment of hypotony and in particular to determine the proportion of cases for which UBM contributed significant additional hitherto unaccessible information. Ultrasound biomicroscopy was performed in a standard manner, using a Humphrey UBM 840 system (Humphrey Instruments, Inc., San Leandro, CA). UBM findings were analysed and the clinical relevance of UBM information was determined for the whole collective. Twelve patients with hypotony were examined. UBM findings contributed essential information that allowed to reach a diagnosis or that determined the therapeutic attitude in 10 of the 12 hypotonic patients. In two cases the cause of hypotony was tractional ciliary body detachment, in 5 cases it was post-inflammatory atrophy of the ciliary body, in 3 cases it was post-traumatic irido and cyclodialysis, in one case it was supraciliary and suprachoroidal effusion and in the last case it was due to uveal effusion syndrome. Based on these findings we established a schematic approach for hypotony. This procedure enabled us to assess the morphological changes found in patients with hypotony. In a majority of cases UBM was useful either to orient therapeutic intervention or to establish a diagnosis. On the base of our findings a schematic approach for hypotony, using UBM, was established.

Descolamento ciliocoroidal e hipotonia causados por supressores do humor aquoso: síndrome da supersensibilidade aos supressores do humor aquoso

Os autores descrevem um caso de hipotonia e descolamento ciliocoroidal que ocorreu com administracao de drogas supressoras do humor aquoso (timolol e acetazolamida) em paciente que havia sido submetido a trabeculectomia (3 meses antes). Por ser o 6° ou o 7° caso descrito na literatura, chamam atencao para esta rara sindrome que inclui a supersensibilidade do corpo ciliar aos supressores do HA, como causa de hipotonia e descolamento ciliocoroidal tardios em pacientes submetidos a cirurgia filtrante. Apresentam tambem um resumo dos casos encontrados na literatura.

A Major Cause of Hypotony

A Major Cause of Hypotony