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[3]Aurich H, Korte P, Wirbelauer C, Haberle H, Pham DT (2007) Iris sutures for refixation of decentered intraocular lenses. Klin Monatsbl Augenheilkd 224: 28−31 [in German]

[4]Boorstein JM, Titelbaum DS, Patel Y, Wong K, Grossman R (1995) CT diagnosis of unsuspected traumatic cataracts in patients with complicated eye injuries: significance of attenuation value of the lens. Am J Roentgenol 164: 181−184

[5]Cionni RJ, Osher RH (1995) Endocapsular ring approach to the subluxed cataractous lens. J Cataract Refract Surg 21: 245−249

[6]DeVaro JM, Buckley EG, Awner S, Seaber J (1997) Secondary posterior chamber intraocular lens implantation in pediatric patients. Am J Ophthalmol 123: 24−30

[7]Kazemi S, Wirostko WJ, Sinha S, Mieler WF, Koenig SB, Sheth BP (2000) Combined pars plana lensectomy-vitrectomy with open-loop flexible anterior chamber intraocular lens (AC IOL) implantation for subluxated lenses. Trans Am Ophthalmol Soc

98:247−251

[8]Lawrence FC 2nd, Hubbard WA (1994) “Lens lasso” repositioning of dislocated posterior chamber intraocular lenses. Retina 14: 47−50

[9]Levy J, Klemperer I, Lifshitz T (2005) Posteriorly dislocated capsular tension ring. Ophthalmic Surg Lasers Imaging 36: 416−418

[10]Loo AV, Lai JS, Tham CC, Lam DS (2002) Traumatic subluxation causing variable position of the crystalline lens. J Cataract Refract Surg 28: 1077−1079

[11]Moisseiev J, Segev F, Harizman N, Arazi T, Rotenstreich Y, Assia EI (2001) Primary cataract extraction and intraocular lens implantation in penetrating ocular trauma. Ophthalmology 108: 1099−1103

[12]Nguyen TN, Mansour M, Deschenes J, Lindley S (2003) Visualization of posterior lens capsule integrity by 20-MHz ultrasound probe in ocular trauma. Am J Ophthalmol 136: 754−755

[13]Pavlovic S (1999) Primary intraocular lens implantation during pars plana vitrectomy and intraretinal foreign body removal. Retina 19: 430−436

[14]Peyman GA, Schulman JA, Sullivan B (1995) Perfluorocarbon liquids in ophthalmology. Surv Ophthalmol 39: 375−395

[15]Pieramici DJ, MacCumber MW, Humayun MU, Marsh MJ, de Juan E Jr (1996) Open-globe injury. Update on types of injuries and visual results. Ophthalmology

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[16]Rao SK, Parikh S, Padhmanabhan P (1998) Isolated posterior capsule rupture in blunt trauma: pathogenesis and management. Ophthalmic Surg Lasers 29: 338−342

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[18]Sasahara M, Kiryu J, Yoshimura N (2005) Endoscope-assisted transscleral suture fixation to reduce the incidence of intraocular lens dislocation. J Cataract Refract Surg 31: 1777−1780

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  2.8    Ciliary Body and Choroid

Ferenc Kuhn

2.8.1Introduction

By secreting aqueous, the ciliary body plays a crucial role in the structural and functional integrity of the eye: even if all other tissues, including the retina, are healthy, loss of aqueous production eventually results in a phthisical, blind eye. The choroid is an elastic tissue that supplies blood for the external retinal layers and the entire anterior segment.

2.8.2Evaluation

The ciliary body is located in a “blind spot” for the examiner, making direct preoperative inspection impossible. Certain pathologies are detectable: gonioscopy may help identifying cyclodialysis, but a more reliable noninvasive method is with the ultrasound biomicroscope (UBM) [8]. Intraoperatively, the ciliary body can be examined with deep scleral indentation or with the endoscope; the latter has several advantages: it gives an image of high resolution and magnification, and without distortion caused by the

Keeping the eye pressurized (“inflated”), nourishing the cornea, accommodation. Gonioscopy is less likely to reveal presence of a cyclodialysis cleft because of interference from commonly coexisting pathologies such as corneal edema and hyphema.

Aniridia greatly enhances inspection of the ciliary body.

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indentation (see Chap. 2.20). The surgeon needs to determine whether the ciliary body is detached and the ciliary processes are healthy.

Monitoring the IOP is the best method to judge the functional viability of the ciliary body, although other factors can also cause hypotony.

Preoperatively, the choroid is best examined with the ophthalmoscope or on ultrasonography.

2.8.3Specific Conditions

2.8.3.1Ciliary Body

2.8.3.1.1 Cyclodialysis

Detachment of the meridional ciliary muscle fibers from the scleral spur (Fig. 2.8.1) allows direct communication between the AC and the suprachoroidal space; even if aqueous production remains unaffected by the trauma , hypotony ensues because of the increased uveoscleral outflow. The size of the cleft has not been proven to correlate with the degree of hypotony.

Regarding treatment, if the cleft does not close spontaneously, it should be treated, especially if secondary complications, such as hypotony maculopathy, develop [17]. In addition to the UBM and preor intraoperative examination using a gonioscopy lens, transillumination during surgery helps determine the exact location of the cyclodialysis. Several options are available to achieve ciliary body reattachment:

•Conservative. Topical atropine to deepen the AC and prevent synechia formation. Anti-inflammatory drugs, such as corticosteroids, are ineffective.

Several of the ciliary body pathologies (e.g., angle recession, ciliochoroidal detachment, phthisis) are discussed in Chaps. 2.18 and 2.19.

Most commonly: contusion.

Fig. 2.8.1  Cyclodialysis cleft imaged on UBM. Expansion of the suprachoroidal space due to detachment of the ciliary body (arrow) (Courtesy of M. Modesti, Rome, Italy)

–Argon laser applied continually over the margins and inside the clefts [1] to block aqueous outflow via choroidal swelling and inflammation (iridocyclitis) [4].

–Transscleral YAG [5] or diode laser [2].

–Cryopexy with deep indentation applied directly over the sclera in the area of the cyclodialysis in a continuous row [3].

•Surgical.

–Diathermy, incorporating both the sclera and the ciliary body [14].

–Suturing, using any of the methods described for iridodialysis (see Chap. 2.16).

“91 burns, 0.45 mW power, 300-µm spot size, 100 µm, 1-s duration”

“20 applications in two rows of ten applications, 2−3 mm behind the limbus, at a power setting of 6 J, with a defocus setting of 9”

“Two rows of 14 applications in a post-traumatic at a power setting of 2500 mW and duration of 2000 ms”

2.8.3.2Choroid

2.8.3.2.1 ECH

No fewer than 19 terms have been used in the literature to describe this condition [11], which is the most devastating complication of open globe surgery. Its incidence in the context of trauma is much less investigated and its importance is certainly underappreciated. In the editor’s own survey of the pathological specimens of 30 eyes enucleated after severe trauma, all had large amounts of suprachoroidal blood, but none of the clinical charts mentioned this complication (see Chap. 1.10).

2.8.3.2.1.1Prevention

The surgeon can reduce the bleeding risk via the follwing:

•The ECH potential must always be kept in mind if an eye sustained serious trauma, whether open or closed globe. Even if suprachoroidal bleeding is not apparent through the pupil and no wound is visible, an ECH may have started but could have been stopped early by the increasing IOP (self-tamponade). Careless examination or reopening of the wound may cause the bleeding to recur or even be its primary cause.

•Avoid putting pressure on the eye during examination (see Chap. 1.9).

•Use caution when reopening the wound for toilette and suture closure. Remember the ECH potential when the timing of intervention is considered: delay of surgery reduces the risk (see Chap. 1.8).

•Topical corticosteroid use reduces vascular engorgement and thus the ECH risk. The drug should be used hourly in the first couple of days.

2.8.3.2.1.2Recognition

The characteristics for recognition are:

•Pain

•Hardening of the eye

•Dark crescent appearing deep inside the eye, disappearing red reflex

•Intraocular tissues pushed forward with eventual extraocular extrusion (Fig. 2.8.2; also see Fig. 2.4.2)

Fig. 2.8.3  “Kissing choroidals” caused by an ECH. The large amounts of suprachoroidal blood push the choroid and retina centrally, until the retinal surfaces are “bridged”

An entirely different situation arises if a retinal prolapse is present. The goal is to preserve as much of the retina as possible by reducing the IOP, repositing the retina without retinectomy if possible, suturing the wound, and addressing the retinal incarceration during a subsequent vitrectomy (see Chap. 2.4).

Drainage is rarely necessary in the acute phase. If there is persistent hypotony or retinal complications, such as retino-retinal bridging (“kissing choroidals”; Fig. 2.8.3), careful reconstruction by a posterior segment surgeon is needed. Timing is important: if the blood is still clotted, it is very difficult to remove, requiring “thrombectomy” [12] with the vitrectomy probe. It takes an average of 10 days for the blood to liquify. Ultrasonography is used to determine when the solid mass turns to fluid.

The procedure is as follows:

•Place an infusion in the AC or through the pars plana if the cannula’s position is possible to verify; a long cannula should be used. The infusion is opened at a pressure of ~35 mmHg. Air or PFCL [7] can be used instead of BSS.

•Identify the highest point of choroidal elevation.11

11The ophthalmoscope or ultrasonography is used to identify the best location for the sclerotomy.

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•Carefully open the sclera. The incision should be perpendicular to the limbus and approximately 2 mm long.12 The blood usually drains spontaneously once the sclera is fully opened. The color of the blood characteristically resembles dark, liquid chocolate.

•Gentle pressure is occasionally necessary to apply over the sclera in the vicinity of the incision: a cotton-tipped applicator is rolled toward the incision to push the blood toward the sclerotomy.

•The same procedure may be repeated elsewhere if high elevation of the ciliary body and choroid after the initial drainage still exists.

•Vitrectomy is performed as required by the intraocular pathologies.13

In most cases, the hemorrhage absorbs spontaneously. If vitreoretinal surgery is necessary for other reasons, drainage may be considered, especially if the suprachoroidal blood is located anteriorly and would interfere with scleral buckling.

2.8.3.2.2 Choroidal Rupture

Choroidal ruptures are breaks in the choroid, Bruch’s membrane, and the RPE. Contusion is the most common cause. In the HEIR database, the incidence is 8% among eyes with contusion but only 1% in ruptures14. Choroidal rupture can occur at the site of impact (direct) or, more frequently, in the back of the eye as the shockwaves are traveling along the eye wall coalesce (contra coup mechanism; indirect). Direct choroidal ruptures are usually parallel to the limbus, whereas indirect ones are concentric to the disc or run in a straight, radial, or vertical line. Multiple ruptures may be present in up to

12If necessary, the incision can also be longer or “L”-shaped.

13Internal drainage of the suprachoroidal blood has also been advocated. This obviously requires a retinotomy, which represents a PVR risk factor and thus significant disadvantage. The advantages are that it is easy to identify the ideal site for the drainage, and that the blood evacuation can be complete even if the hemorrhage is poster­ ior.

14When the eye ruptures, this appears to act as a pressure valve, reducing the risk of choroidal rupture.