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CASE REPORT
Year : 2016  |  Volume : 23  |  Issue : 3  |  Page : 265-267  

Achieving controlled intraocular pressure and restoration of vision following proactive treatment of total choroidal detachment due to endocyclophotocoagulation


Department of Ophthalmology, Specialized Medical Center Hospital; Department of Ophthalmology, College of Medicine, Imam Mohammed bin Saud Islamic University, Riyadh, Saudi Arabia

Date of Web Publication12-Jul-2016

Correspondence Address:
Tariq Al-Asbali
Department of Ophthalmology, College of Medicine, Imam Mohammed bin Saud Islamic University, P. O. Box 5701, Othman Ibn Affan Street, Riyadh 11432
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.186152

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   Abstract 

Ocular hypotony due to choroidal detachment (CD) following endocyclophotocoagulation (ECP) is transient. If hypotony lasts for more than 1 week, it could affect vision. This is a case of refractory glaucoma following cataract surgery that was managed by ECP. We drained subchoroidal fluid as CD did not resolve after 1 week. After 5 months, the intraocular pressure was restored to 16 mmHg with one topical glaucoma medication, uncorrected vision improved to 20/300, and with aphakic soft contact lens, it was 20/50. Ophthalmologists facing such complications need not panic and manage hypotony, and the prognosis of such intervention seems to be promising.

Keywords: Choroidal Detachment, Cyclophotocoegulation, Glaucoma


How to cite this article:
Al-Asbali T. Achieving controlled intraocular pressure and restoration of vision following proactive treatment of total choroidal detachment due to endocyclophotocoagulation. Middle East Afr J Ophthalmol 2016;23:265-7

How to cite this URL:
Al-Asbali T. Achieving controlled intraocular pressure and restoration of vision following proactive treatment of total choroidal detachment due to endocyclophotocoagulation. Middle East Afr J Ophthalmol [serial online] 2016 [cited 2019 Jul 20];23:265-7. Available from: http://www.meajo.org/text.asp?2016/23/3/265/186152


   Introduction Top


Endocyclophotocoagulation (ECP) is the recommended treatment for refractory glaucoma. [1],[2] The incidence of choroidal detachment (CD) as a complication of ECP ranges from 4% to 14%. [3],[4] In more than 80% of eyes, the hypotony is transient in nature and lasts for 1 week. [3] Hypotony 1-week after management of refractory glaucoma is unusual and requires proactive intervention. We present a case of total CD with hypotony lasting for longer than 1 week after ECP. Treatment of this case results in vision restoration and maintains the target intraocular pressure (IOP).


   Case report Top


A 35-year-old female presented in January 2015 with complaints of dimness of vision and pain in left eye. She had undergone cataract surgery with intraocular lens (IOL) implantation in her left eye elsewhere 7 years prior to presentation. Postoperatively, she developed glaucoma, which did not resolve with medical treatment. Hence, the IOL was explanted. Still IOP remained high; therefore, trabeculectomy was performed but failed after 6 months. She was subsequently treated a number of glaucoma medications including brimonidine, dorzolamide, latanoprost, and timolol.

At presentation to our eye clinic, she was using three glaucoma medications. The right eye (OD) had a distance visual acuity of 20/20 and vision was counting fingers at ½ m with projection of light in all four directions in the left eye. The right eye had normal anterior and posterior segments on slit-lamp examination, and IOP by applanation tonometer was 16 mmHg.

The left eye had conjunctival and circumciliary congestion, but the cornea was not edematous, and there was no opacity or endothelial decompensation. The pupil was not round but peaked and had sluggish reaction to light. The anterior camber was deep and lens was absent. The gonioscopy revealed open angle of anterior chamber in both eyes. The left eye however had pigments at trabecular meshwork. The anterior phase of vitreous was intact. Prior to dilatation, we noted peripheral iridectomy in the left eye in the meridian of peaked pupil and fibrous strands were visible. Posterior segment examination using +20 D lens (Volk Optical Inc., Mentor, OH, USA) indicated myopic retinal degeneration. The cup-disc ratio was 0.7 with thinning of the neuroretinal rim in comparison to the optic nerve head (ONH) of the fellow eye. The IOP was 46 mmHg.

To control IOP in the left eye, we prescribed acetazolamide 250 mg tablets qid, latanoprost eye drop once daily, dorzolamide + timolol eye drops twice daily, and brimonidine eye drops twice a day. The patient was fitted with a soft contact lens with aphakic correction and the vision improved to 20/50.

The patient was referred to a glaucoma subspecialist and consented to secondary IOL implantation with ECP in the left eye.

One hour prior to surgery, IOP was reduced to 14 mmHg with intravenous acetazolamide 500 mg PO/IV. The opening of anterior chamber through corneal wound was uneventful. We used ECP machine (Endo Optiks, Germany) with curved probe and laser power levels of the 810 nm semiconductor diode laser titrated upward from lower power levels to achieve whitening and shrinkage of the ciliary processes under direct visualization. After 7 min of ECP covering 270° of ciliary processes, total choroid detachment developed [Figure 1]. Hence, the surgery was stopped, the IOL was not implanted, and the corneal wound was closed ensuring it was watertight.
Figure 1: Eye with choroidal detachment following endocyclophotocoagulation

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B-scan ultrasonography of the left eye 24 h postoperatively revealed hemorrhagic CD with kissing choroids. IOP was 26 mmHg and the patient could perceive light in the operated eye.

The patient was prescribed acetazolamide 250 mg tablets qid, dorzolamide + timolol eye drops bid for 1 week. On follow-up, the IOP was 26 mmHg and ultrasonography indicated no change in amount of fluid in suprachoroidal space. Subsequently, two temporal sclerotomies were performed, drained subchoroidal hemorrhagic fluid under sterile condition, and left the sclerotomy wounds open for drainage.

One week postoperatively, the visual acuity in the left eye was 20/600, IOP was 20 mmHg with a flat retina with residual suprachoroidal fluid nasally, and ONH was glaucomatous with adequate vasculature.

The CD had resolved completely after 2 weeks, the vision in left eye was 20/400 without correction, and IOP was 16 mmHg without any glaucoma medication.

The IOP 4 weeks postoperatively was 24 mmHg with latanoprost eye drop once daily, and the IOP remained stable for next 5 months (last follow-up) [Figure 2].
Figure 2: Eye after draining the subchoroidal fluid

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   Discussion Top


IOP within normal limits without any ONH change in the fellow eye suggested that this was a case of unilateral aphakic glaucoma. Despite medical treatment following glaucoma surgery, the IOP remained high. Hence, by the time the patient presented to our hospital, we diagnosed the patient with refractory glaucoma in the left eye. We concluded that it could be a case of open-angle glaucoma missed at the time of cataract surgery. The ophthalmologist aimed to provide good functional vision along with treatment of glaucoma by planning a secondary IOL implantation with ECP. Possibility of retinal complications including hemorrhagic CD is documented and they were explained to the patient. [5] Intraoperatively, we found no evidence of hypotony and expulsive hemorrhage. Near completion of ECP, CD was noted. Thus, sudden hypotony following opening of the globe with a history of high IOP is not likely the cause of CD in our case. The exact explanation for CD in this case is difficult. However, there could be extravasation of fluid in suprachoroidal space as reaction to thermal injury to ciliary body, or it could be due to change in IOP after opening the vitreous cavity for ECP resulting in breaks in choriocapillaris.

Vitreous had not herniated in either anterior chamber or in the wound. The iris picking was due to fibrosis between peripheral iridectomy and decentered lens after cataract surgery perhaps due to postoperative inflammation. We believe that this should be either left alone or managed at the time of secondary lens implantation if subsequent surgery is planned.

Choroidal effusion following trabeculectomy, a very common glaucoma surgery, is not an unusual complication and review has suggested that careful patient selection and timely management helps in preventing sight-threatening consequences. [6],[7] Sclerotomy is an effective mode of managing uveal effusion syndrome. [8] Good visual recovery following management of CD in an eye with a ruptured globe has been documented, and OCT findings were predictors of visual outcomes in these cases. [9] However, visual recovery and maintenance of IOP for 6 months following proactive intervention are worth noting.


   Conclusion Top


If total CD after ECP is managed properly, the target IOP can be successfully controlled and vision restored.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Huang G, Lin SC. When should we give up filtration surgery: Indications, techniques and results of cyclodestruction. Dev Ophthalmol 2012;50:173-83.  Back to cited text no. 1
    
2.
Morales J, Al Qahtani M, Khandekar R, Al Shahwan S, Al Odhayb S, Al Mobarak F, et al. Intraocular pressure following phacoemulsification and endoscopic cyclophotocoagulation for advanced glaucoma: 1-year outcomes. J Glaucoma 2015;24:e157-62.  Back to cited text no. 2
    
3.
Lima FE, Magacho L, Carvalho DM, Susanna R Jr., Avila MP. A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma. J Glaucoma 2004;13:233-7.  Back to cited text no. 3
    
4.
Hoeh H, Ahmed II, Grisanti S, Grisanti S, Grabner G, Nguyen QH, et al. Early postoperative safety and surgical outcomes after implantation of a suprachoroidal micro-stent for the treatment of open-angle glaucoma concomitant with cataract surgery. J Cataract Refract Surg 2013;39:431-7.  Back to cited text no. 4
    
5.
Ho TT, Kaiser R, Benson WE. Retinal complications of cataract surgery. Compr Ophthalmol Update 2006;7:1-10.  Back to cited text no. 5
    
6.
Schrieber C, Liu Y. Choroidal effusions after glaucoma surgery. Curr Opin Ophthalmol 2015;26:134-42.  Back to cited text no. 6
    
7.
Bakir B, Pasquale LR. Causes and treatment of choroidal effusion after glaucoma surgery. Semin Ophthalmol 2014;29:409-13.  Back to cited text no. 7
    
8.
Chan W, Fang-tian D, Hua Z, You-Xin C, Rong-ping D, Ke T. Diagnosis and treatment of uveal effusion syndrome: A case series and literature review. Chin Med Sci J 2011;26:231-6.  Back to cited text no. 8
    
9.
Andreoli MT, Yiu G, Hart L, Andreoli CM. B-scan ultrasonography following open globe repair. Eye (Lond) 2014;28:381-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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