An Airbag Deploys, Leaving Vision Blurry and Distorted Despite Treatment

Ronald C. Gentile, MD; Jessica Lee, MD

Disclosures

February 26, 2016

Case Diagnosis

The history, slit-lamp examination, intraocular pressure, gonioscopy finding, UBM, and fundus appearance support the diagnosis of a cyclodialysis cleft with secondary hypotonus maculopathy. UBM confirmed the diagnosis of a cyclodialysis cleft, imaging a disinsertion of the ciliary body from the scleral spur. The hypotony was caused by aqueous humor flow into the suprachoroidal space from the anterior chamber and resulted in choroidal effusions, chorioretinal folds, shallowing of the anterior chamber, axial length shortening, and a hyperopic shift.

Even though a rupture of the globe can cause hypotony and needs to be ruled out in all cases of blunt trauma, the absence of any full-thickness corneal or scleral wound rules out an open globe injury. If a subconjunctival hemorrhage or chemosis prevents adequate evaluation of the sclera, surgical exploration may be needed. Besides hypotony, other clinical signs of a ruptured globe include an irregular peaked pupil, vitreous hemorrhage, and vitreous incarceration, which were not noted in our case.

Uveitis can also cause hypotony and is usually related to both decreased aqueous humor production and increased uveoscleral outflow. Low intraocular pressure in uveitis typically increases as the inflammation improves, which we did not observe. In our case, the hypotony actually worsened over time despite treatment with a topical corticosteroid. This was most likely related to improved aqueous flow through the cleft as the hyphema and inflammatory cells cleared. Many traumatic cyclodialysis clefts spontaneously close as a result of inflammation-associated scarring.

A retinal detachment occurs when the neurosensory retina separates from the retinal pigment epithelium owing to accumulation of subretinal fluid. A rhegmatogenous retinal detachment occurs when the fluid comes through a retinal break or hole. Hypotony can occur in the setting of a retinal detachment as intraocular fluid is pumped across the retinal pigment epithelium. Even though our patient had peripheral retinal elevations, the absence of open retinal breaks rules out a rhegmatogenous retinal detachment. The peripheral retinal elevations were serous choroidals and secondary to the hypotony, also commonly seen with cyclodialysis clefts.

Clinical Course

After medical management was unsuccessful in eliciting spontaneous closure of the cyclodialysis cleft with discontinuation of topical corticosteroids and addition of a more potent cycloplegic agent (atropine sulphate 1% twice a day), the patient underwent laser treatment. Argon thermal laser was applied deep into the cleft, first to the sclera and then to the exposed ciliary muscle. This technique incites focal inflammation that can seal the cleft by promoting adhesion between the choroid and sclera.

After laser treatment, the patient's intraocular pressure spiked to 50 mm Hg, requiring short-term systemic and topical glaucoma medications.

Vision eventually improved to 20/20 after traumatic cataract removal and intraocular lens implant, with normalization of the intraocular pressure to 12 mm Hg without medication. The macular folds and the patient's distortion resolved.

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