Wang Hongge, Dong Xiaoguang, Yang Sugih Studio Ophthalmology Wang Hongge
Patient Han XX, male, 24 years old, came to our hospital on August 6, 2004 for “six months of blurred vision after a boxing injury to the right eye”. The patient’s vision decreased after a boxing injury to his right eye six months ago, and his vision was distorted without any other discomfort. A week later, he was seen at a local hospital and diagnosed with “choroidal laceration and vitreous hemorrhage in the right eye,” with an intraocular pressure of 10 to 12 mmHg. The ultrasound examination showed choroidal detachment in the right eye, and the second ultrasound biomicroscopy (UBM) examination did not find the ciliary detachment, so hormonal treatment was given. Afterwards, the visual acuity improved, but the IOP did not improve.
The right eye had 0.2 naked visual acuity, 0.5 foramen ovale, -2.00DS = 0.4, 4 mmHg IOP, normal photopic localization and photochromatic perception, clear cornea, shallow Ⅰ° anterior chamber, significant peripheral area, significant pigment loss in the mid-periphery of the iris, round pupil, 4 mm in diameter, photoreactive, clear crystal, mild gray-white flocculent clouding of the vitreous body, and a small amount of old blood in the lower part. Ultrasound showed: superficial choroidal detachment, vitreous clouding; UBM showed: shallow anterior chamber, extensive anterior iris adhesions, atrial angle closure in all directions, residual gap in the crypt, extensive leakage from the nasal side of the superior ciliary body. No significant detachment of the ciliary body was seen. Optical coherence tomography (OCT): Mild edema in the macula. Atrial angles showed narrow Ⅲ° superior, nasal and temporal atrial angles and Ⅱ° inferior atrial angles, and no ciliary detachment due to low IOP. The left eye had a bare visual acuity of 1.0 and an intraocular pressure of 11 mmHg. On examination, only the mid-peripheral pigment loss below the iris was observed, and no other abnormalities were seen.
The diagnosis: right eye: ciliary detachment pending drainage, choroidal detachment, macular edema, vitreous opacities, and old blunt contusion of the eye.
The patient was admitted to the hospital, and after bandaging both eyes for 2 days, atrial angioscopy and UBM were performed again without finding the ciliary detachment opening, so Healon injection was performed in the right anterior chamber of the eye under peribulbar block anesthesia, and UBM was performed again with deepening of the anterior chamber, especially the peripheral anterior chamber. After the location of the ciliary detachment opening was clarified, a suture repositioning of the ciliary body in the right eye was performed. A scleral flap of approximately one-half thickness was made at 4 mm from the corneoscleral margin, and a superficial scleral flap was made underneath, 2.5 mm from the corneoscleral margin
Author Affiliation：250001 Shandong Provincial Eye Hospital
Correspondence should be addressed to Dong Xiaoguang E-mail:[email protected] Tel: (0531)86312177
The deep sclera was incised in full layer, the dislocated ciliary body underneath it was exposed, and the ciliary body was sutured to the scleral wall in the range of about 1.5 bells at 2:45-4:15, and the operation went smoothly. Postoperatively, the patient’s IOP returned to normal, fluctuating between 10 and 14 mmHg. He was discharged on the 6th postoperative day with visual acuity of 0.25 in the right eye and IOP of 14 mmHg. UBM confirmed ciliary body repositioning and mild leakage in the 3 to 4 point range on the nasal side. UBM confirmed that the ciliary body was repositioned and the macula was mildly leaking in the area of the nasal 3 to 4 points. Atrial angle microscopy: Mild atrial angle recession in the nasal 3 to 4 o’clock range, all atrial structures were visible in the rest of the range. The left eye had a bare visual acuity of 1.0, IOP = 10 mmHg, and no other abnormalities were seen in the mid-peripheral depigmentation below the iris.
Discussion Ciliary detachment is a cleft between the ciliary body and its attached scleral crest, resulting in an open suprachoroidal space that communicates with the anterior chamber [1]. In terms of treatment, it can be observed for 6 to 8 weeks in the early stages and atropine helps to reset the ciliary body. Argon laser and freezing can artificially create inflammation and reset it. The most reliable treatment is surgical fixation of the ciliary body to the scleral wall [2]. Ciliary body detachment is common in ocular trauma and can cause shallow anterior chamber with low IOP due to excessive and rapid atrial fluid drainage through the detachment opening into the suprachoroidal space. In the case of shallow anterior chamber, it can form pre-iris adhesions around the atrial angle and closure of the atrial angle, and the contact between the iris surface and the corneal endothelium destroys the corneal endothelium, causing corneal endothelial cell function loss and corneal edema. Low intraocular pressure can cause retinal folds, choroidal detachment, optic nerve and macular edema, which can seriously affect vision. Thus, ciliary detachment needs to be reset promptly to avoid complications. In most patients, the location and extent of the ciliary detachment can be determined by atrial angioscopy or UBM, which can guide surgery to reposition the ciliary body. However, if the patient has a small ciliary detachment and a shallow detachment, combined with factors such as sometimes an extremely shallow anterior chamber, it is difficult to locate the detachment opening under atrial angioscopy. In this case, the affected eye can be bandaged with pressure and the patient can be put on bed rest for a day or two and then examined with atrial angioscopy may also be found, but it must be done quickly, otherwise the IOP drops quickly and the anterior chamber becomes shallow affecting the examination. UBM is also not easily found in such cases, as was the case in this patient. We used a lateral corneal rim incision to inject Healon into the anterior chamber to deepen the anterior chamber to a certain depth, especially in the peripheral part of the anterior chamber, so that the peeling opening was more obvious. Then, we can easily find the location and extent of the detachment opening by performing atrial angle microscopy during surgery or atrial angle microscopy or UBM examination out of the operating room, which significantly improves the success rate of the surgery. The authors have conducted English and Chinese searches and have not seen any reports in this regard. We would like to introduce it here in the hope that it will be helpful to all ophthalmology colleagues in their clinical work.
References
1. Zhao M. W., ed. Ocular Trauma and Ophthalmic Emergencies Management. Beijing: People’s Health Publishing House, 2001, 224.
2. Translation by Xie Lixin. Ophthalmic Surgery. Beijing: People’s Health Publishing House, 2004, 358-359.