placement of dual capsular tension rings for the combined management of traumatic cyclodialysis cleft and zonular dialysis

背景

To evaluate the efficacy and safety of placing dual capsular tension rings for the combined management of traumatic cyclodialysis cleft and zonular dialysis.

Methods

在20例连续的患者中，将一个修饰的囊张环插入睫状沟中，并在20例连续的患者中插入20只眼睛的囊袋中的囊张环或修饰的囊状张力环。结果指标包括眼内压，最校正的视力和术后并发症。

Results

在20例平均年龄为48.7岁的患者中，进行了双囊张环的放置。环透度裂口延长了2.9时钟小时（范围0.5-6.5）。修改后的囊张张力环成功地插入了睫状沟中，所有眼睛的囊袋中的囊张环或修饰的帽张力环。在最后一次随访中，循环透析裂缝在16/20（80.0％）的眼睛中闭合。术后所有患者的眼内镜头均稳定。根据最小分辨率的对数，最校正的视力从手术前的1.3±0.8提高到手术后的0.4±0.3（p < 0.001). Intraocular pressure increased significantly from 10.6 ± 3.2 mmHg before surgery to 13.0 ± 4.8 mmHg after surgery (p = 0.040). Postoperative complications included a painful reversible intraocular pressure spike in four patients (20.0%). Logistic regression revealed no significant factors associated with successful cleft closure and a stable final intraocular pressure of ≥ 10 mmHg.

Conclusions

The placement of two capsular tension rings into the ciliary sulcus and the capsular bag is a safe, successful procedure combined for repairing a traumatic cyclodialysis cleft and managing zonular dialysis.

Cyclodialysis clefts form due to incorrect insertion of the meridional ciliary fibers in the scleral spur, creating a secondary pathway that allows aqueous humor to drain into the suprachoroidal space [1，，，，2，，，，3]。A cyclodialysis cleft combined with zonular dialysis is a rare disorder that usually occurs following blunt ocular trauma, and usually leads to persistent hypotony, cataract, and ectopia lentis. It is often difficult to diagnose and treat this traumatic complication due to its rarity and subtle clinical signs [1]。及时的检测和准确的管理，以恢复分离的睫状体的体现和脱位镜头对于确保术后视觉恢复至关重要。

已经提出了各种非手术和外科手术方法来关闭环透透析裂缝并居中脱位的晶状体[4，，，，5，，，，6，，，，7，，，，8，，，，9，，，，10，，，，11，，，，12，，，，13]。Gupta et al. [11] reported a case of cataract, zonular dialysis, cyclodialysis, and iridodialysis following blunt trauma that was successfully treated in a single procedure by placing two capsular tension rings (CTRs). We previously performed phacoemulsification combined with an internal tamponade by insertion of a modified capsular tension ring (MCTR) into the ciliary sulcus to close cyclodialysis clefts and treat cataracts [12，，，，13]。Appropriate positioning of a polymethyl methacrylate CTR or Cionni MCTR in the sulcus apposing the detached ciliary body against the sclera provides stable endocyclotamponade and endocyclopexy (in-out suture to aid fixation), which promotes cleft closure [8，，，，9，，，，13，，，，14]。Similarly, implantation of an MCTR, an adjacent zonular apparatus, achieved the best possible outcomes in terms of long-term stability and centering of the intraocular lens (IOL) in patients with ectopia lentis following continuing refinement of surgical techniques [15，，，，16，，，，17]。

Surgical interventions are usually essential for traumatic cyclodialysis cleft, which is often accompanied by other ocular injuries. Performing multiple surgical procedures in a single operation can avoid the burden associated with multiple procedures, general anesthesia, and postoperative morbidity, and can make the procedure more cost-effective for the patient and hospital. In this study, we describe the efficacy and safety of inserting an MCTR into the ciliary sulcus and a CTR or MCTR into the capsule for traumatic cyclodialysis cleft and zonular dialysis in a single procedure, in a series of consecutive patients with cyclodialysis cleft and zonular dialysis.

Ethics approval

The Institutional Review Board of the Eye and ENT Hospital of Fudan University, Shanghai, China, approved this study (No.2013021). All procedures were conducted following the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients.

patient eligibility

在2017年1月至2019年12月（包括连续的患者）参加了中国上海福丹大学眼科诊所的连续患者，他们满足了这项前瞻性病例系列研究。具有创伤性眼损伤的患者导致循环透析裂缝和小叶透析，并将MCTR联合插入纤毛沟中，而CTR或MCTR将MCTR插入胶囊袋中是符合条件的。排除标准是玻璃体视网膜手术，自发闭合或通过直接环形闭合。通过超声生物显微镜（UBM）证实了环透析裂裂和小叶透析。

Surgical technique

A superior clear corneal tunnel incision and paracentesis were made under retrobulbar anesthesia or general anesthesia. An ophthalmic viscosurgical device (OVD) was injected intracamerally to enable anterior continuous curvilinear capsulorhexis, the fixation of capsule hooks, and hydrodissection. Following standard stop and chop or tilt and tumble phacoemulsification technique and cortical aspiration, the viscocohesive OVD was then re-injected into the capsular bag. A CTR (Morcher Type 14C, Type 14A or Type 14, GmbH, Germany) or an MCTR (Morcher Type 1 L or Type 2C, GmbH, Germany) with one eyelet preset with 9–0 polypropylene aligned along the area of zonular dialysis was implanted into the capsular bag to support the zonules, after which a foldable IOL was inserted into the capsule. In some eyes, the cortices were aspirated after inserting the CTR or MCTR into the capsular bag. After dealing with the zonular dialysis, a 13-mm Morcher Type 2 L CTR (Morcher GmbH, Germany), an MCTR with two eyelets preset with 10–0 polypropylene was then positioned into the ciliary sulcus, and the end of the prolene suture was tied to the sclera 1 mm posterior to the surgical limbus. The position of one eyelet was pushed towards the maximum height of the cleft, which resulted in the reattachment of the detached ciliary body to the scleral spur by direct mechanical tamponade. The surgery was concluded by aspirating the OVD and closing the corneal wound (Fig.1）。

结果措施

术前数据包括人口统计学特征，创伤病史，创伤持续时间，最校正的视力（BCVA），眼内压（IOP），前室深度（ACD），环虫透析的数量和大小。在所有患者中，在所有患者中都进行了缝隙灯 - 扫描超声检查，B-SCAN超声检查（OCT5000，Carl Zeiss Meditec，Inc。，CALINGING）和UBM（MD-300 L，MEDA，MEDA，TIANJIN，中国）。成功的措施包括将IOP提高到≥10mmHg，确认UBM上的裂解裂解以及在SLIT-LAMP检查下确认IOL核心。术后数据包括随访的持续时间，最大IOP，IOP稳定性以及成功关闭裂缝的眼睛比例。

Statistical analysis

Statistical analyses were performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics are presented as the mean ± standard deviation and range, where appropriate. Student’s pairedt-test was used to compare preoperative and postoperative measurements within the whole group. The Student’st以及申请pati之间的比较ents with and without retinopathy. Logistic regression was used to determine which factors were associated with successful cleft closure or IOP recovery using age, the time between trauma and surgery, preoperative parameters, and cleft size as possible factors. The results of two-sided tests were considered statistically significant atp < 0.05.

A total of 20 patients (20 eyes) were enrolled and underwent dual insertion of CTRs to repair a cyclodialysis cleft and correct ectopia lentis. An MCTR with two eyelets was successfully inserted into the ciliary sulcus in all patients, a CTR was inserted into the capsular bag in 13 patients and an MCTR with one eyelet was inserted in seven patients. The mean ± SD age of the patients at the time of surgery was 48.7 ± 10.7 years (range, 31–74 years) and 75% were male. The affected eye was the right eye in 12 patients (60%). The procedure was performed at a mean of 7.9 months after ocular trauma (range, 15 days to 36 months), excluding one patient in whom the duration was unclear from the medical records. The baseline clinical features of the patients can be found in Table1。

所有患者均有一个循环透析（图。2a & b). The extent of the cyclodialysis cleft was 2.9 ± 1.4 clock hours (range 0.5–6.5), and most of the patients (90%) had a large cleft (≥ 1.5 clock hour). The location of the cleft varied and the cleft affected one quadrant (3 clock hours) in 14 patients, one to two quadrants (3 to 6 clock hours) in five patients, and three quadrants (> 6 clock hours) in one patient.

Significant ocular complications included traumatic cataract in 19/20 eyes (95.0%), choroidal detachment in 18 eyes (90.0%, Fig.2c), anterior chamber angle closure in five eyes (25%), hypotonic maculopathy in five eyes (25.0%), macular edema in four eyes (20.0%), iridodialysis in three eyes (15.0%, Fig.2d），两只眼睛（10.0％）中的玻璃体疝，两只眼睛（10.0％）的角度衰退，两只眼睛（10.0％）中的视网膜膜（10.0％）。以前三只眼睛已经接受了手术手术，包括两名患者（＃1和6）的外部直接环形修复以及一名患者的角膜裂缝（＃14）。我们的任何患者均未进行玻璃体视网膜手术。患有和没有视网膜病的患者之间的术前和术后BCVA和IOP没有显着差异（所有p > 0.05, data not shown).

The preoperative BCVA, in logarithms of the minimal angle of resolution (logMAR), ranged from 0.2 to 3.0 (mean ± SD 1.3 ± 0.8) and preoperative IOP ranged from 6.0 to 16.8 mmHg (mean ± SD 10.6 ± 3.2 mmHg; 1 mmHg = 0.133 kPa). Postoperatively, BCVA (logMAR) improved to 0.4 ± 0.3 (p < 0.001) and IOP increased significantly to 13.0 ± 4.8 mmHg (p = 0.040). Postoperatively, the IOP returned to normal (≥ 10 mmHg) in 15 eyes (75.0%) at different times after the procedure. Four patients (20.0%) experienced a postoperative IOP spike several days after surgery, of which two required antiglaucoma drugs to control their temporary IOP elevation. The postoperative IOP spikes were reversible, and none of the patients had a persistent elevated IOP and none required antiglaucoma surgery.

没有如shallo术中并发症w anterior chamber, capsular hook slipping, vitreous prolapse, iris injury, anterior capsular tear, and posterior capsular rupture, occurred in any patients. All of the patients were followed up at a mean ± SD of 2.3 ± 1.9 months after the procedure. At the last follow-up, the cyclodialysis cleft was successfully closed in 16/20 (80.0%) eyes, indicating a favorable anatomic prognosis. IOL was stable in all patients (20 eyes, 100.0%) postoperatively. The confirmation of cleft closure was shown on UBM and a double indentation sign of two arc-shaped strong echoes with multiple reflections was presented after reattaching the ciliary body to the scleral spur by a Cionni MCTR and inserting a CTR into the capsular bag (Fig.3）。

逻辑回归表明，成功的裂口成功与年龄无关（p = 0.310), duration of hypotony (p = 0.340), cleft size (p = 0.176), preoperative BCVA (p = 0.662), or preoperative IOP (p= 0.790)。此外,最终的IOP≥10毫米汞柱was not significantly associated with age (p = 0.616), duration of hypotony (p = 0.430), cleft size (p = 0.501), preoperative IOP (p = 0.147), postoperative IOP spike (p = 0.458), and preoperative ocular complications (p = 0.387 for choroidal detachment;p = 0.572 for iridodialysis).

The repair of traumatic dialyses is vital to restore eye anatomy and achieve optimal visual outcomes. In eyes with a small cyclodialysis cleft (< 1.5 clock hours), conservative therapy offered good prognosis following medical and argon laser photocoagulation [18，，，，19，，，，20]。However, surgical procedures are inevitable for larger cyclodialysis clefts, especially in eyes with coexisting cataract and ectopia lentis, and a single procedure may be preferred over multiple surgical procedures [13]。

Owing to the variable manifestations of cyclodialysis cleft and coexisting complications of ocular trauma, ophthalmic surgeons need evidence-based guidance and must select the most appropriate intervention that can effectively close the cleft and treat the complications [2]。尽管此处描述的外科手术可能很漫长，但这被术后短期康复期所抵消。迄今为止，我们已经进行了20例创伤性循环裂解，散发透析和其他相关病理的患者的组合手术程序，其中没有一个经历过严重的并发症，例如眼内出血，前室，浅，帽钩，玻璃纤维刺，玻璃体蒸发，玻璃体生殖，iiotrogentiric Iridodicodiatosisis，，前囊撕裂或后囊破裂。BCVA改善，术后IOP显着增加。这种使用双CTR的方法也是最少的侵入性，并且在技术上很简单。

纵向睫状肌纤维脱离巩膜刺激性后，循环裂解的形成形式，并且从晶状体缘缘的起源中插入不正确的纤毛体可能会导致碎石性弱点和透镜subluxation [1，，，，13，，，，21]。Once the ciliary body is mechanically reapposed to the scleral spur, there is no need to insert a CTR or MCTR into the capsular bag because the zonules tighten and the capsule centers. Zonular dialyses with different circumferences of involvement are manifested by zonular weakness and displacement of the crystalline lens, and they should be carefully evaluated before surgery [22]。在眼部创伤中经常出现的小叶透析可能会导致术后囊囊 - 元素复合物的倾向和倾斜，因此应将MCTR插入囊袋中，以确保稳定的长期支撑[23]。In our study, 13 of the 20 patients underwent in-the-bag CTR insertion and seven patients underwent in-the-bag insertion of an MCTR with one eyelet, maintaining perfect IOL centration.

循环透析会产生一种异常的途径，以使水幽默排入螺旋体空间，从而导致下降和脉络膜脱离。但是，本研究中的一些患者在存在环透析裂和脉络膜脱离的情况下显示出> 10 mmHg的IOP。眼部伴随病理，例如浅前腔，前节炎症，玻璃体脱垂，周围前侧旁神经，前腔角闭合以及镜头的前置换可能会降低幽默的流体，并增加IOP的流体。

Internal tamponade together with implantation of a CTR and IOL into the ciliary sulcus has also been proposed for repairing a cyclodialysis cleft [7，，，，9，，，，14，，，，24]。After rotating one of the IOL haptics to face the site of the cyclodialysis cleft, the IOL forces the ciliary body to the sclera spur, thereby closing the cyclodialysis cleft [7，，，，24]。However, the potential risk of ciliary body erosion, hemorrhage, pain, and inflammation from the compressive effects of the stiff IOL haptics should not be ignored [3]。In eyes with a large cleft, the IOL haptic would not provide adequate support by direct apposition of the ciliary body to the sclera spur. Inserting a CTR into the capsular bag can provide stability for the capsule–IOL complex, but the CTR does not exert a direct tamponade force to reattach the detached ciliary body to the ciliary sulcus because the capsule may limit the extent of CTR expansion. To restore ocular anatomy, an in-the-bag IOL is a more reasonable approach to avoid postoperative refractive surprise, despite a reduction in axial length due to hypotony, and hence achieve optimal visual recovery [9]。

As a mean diameter of the ciliary sulcus is 12.0 to 12.5 mm in nearly emmetropic adult eyes, a non-compressed Morcher Type 2 L MCTR with a diameter of 13.0 mm is suitable for side-to-side placement and presumably effective internal tamponade in the ciliary sulcus. Using the optimal MCTR size, the force was exerted not only by the ring on the ciliary sulcus to provide internal tamponade, but also ab-interno suturing of the eyelet of the MCTR for reattachment of the ciliary body.

在循环透析裂缝的情况下，结合玻璃体出血，玻璃体切除术，内吞凝和气体/有机硅油内托管治疗是不可替代的技术[25]。在缺乏术前玻璃体视网膜严重并发症的情况下，left裂修复和IOP归一化后可能会良好的视觉恢复患者。在这项研究中，患者患有循环性裂解和其他眼部并发症，包括创伤性白内障，易lane骨，脉络膜脱离，折射率误差，低音斑点肿瘤，黄斑肿瘤，黄斑水肿和上尾膜，通常会严重影响视觉。术后视力似乎主要取决于黄斑疤痕和视网膜脱离的存在，而不是透析的延伸或伴随病理学的存在，因为我们发现患有和后的术前和后BCVA在患者和后的术后BCVA没有显着差异。没有视网膜病。

有四个成功裂患者closure at the last follow-up. Two patients with sustained 4- and 4.5-clock hour clefts had incomplete cleft closure but their IOP stabilized at 10 mmHg. It is speculated that the production and outflow rate of aqueous humor might reach an equilibrium in both of these patients as traumatic synechia or iridial inflammation increased the IOP and some small clefts decreased the IOP. Therefore, they did not undergo further treatments, and a long-term follow-up was scheduled. One case with a 3-clock hour cleft had multiple complications, including traumatic cataract, ectopia lentis, macular edema, choroidal detachment, and angle recession. B-scan ultrasonography examination showed a slight detachment of the choroid. Further UBM examination should be done to confirm the existence of a small cleft during the follow-up. This patient may need argon laser treatment to improve the IOP to more than 10 mmHg. The fourth case was a young male with a 6-clock hour cyclodialysis cleft. Closure of the most severe clefts was confirmed, but small clefts remained, and they required long recovery time and laser photocoagulation treatment.

Some key aspects of our procedure warrant attention. First, for patients with the insertion of two MCTRs, it is vital to determine the most severe position of the dislocated lens and the maximum height of the cleft preoperatively, to ensure the sutures that fix both MCTRs are passed around the interlamellar sclera and the two eyelets of the dual MCTRs should be staggered. Second, if miosis occurs during MCTR insertion into the ciliary sulcus, it is helpful to switch from capsular retractors to iris hooks. Third, when inserting an MCTR with two eyelets into the ciliary sulcus, the suture placed on the side of the cleft should be pulled tightly, whereas the opposite suture should be fixed gently to avoid warping the MCTR against the iris. Finally, it is not necessary to completely aspirate the peripheral OVD because a high postoperative IOP facilitates cleft closure.

We appreciate there are some limitations to estimating the surgical outcomes of dual CTRs insertion for the treatment of cyclodialysis and zonular dialysis in a small cohort, which is due to the relative rarity of this pathology. The results of our efforts to develop a safe and minimally invasive method for the treatment of ocular traumatic dialyses seem to be favorable. However, larger controlled studies are needed to verify the results. In this short-term study, we did not perform comparisons with other surgical methods, such as inserting an IOL into the ciliary sulcus, although we did observe a favorable success rate following dual CTRs insertion. Our study provides an alternative option for ophthalmologists to treat ocular dialyses.

创伤cyclodialysis裂复杂与zonular dialysis is an uncommon complication that requires successful repair to ensure anatomic correction and improvement in visual function. Delaying treatment might lead to a permanent visual deterioration and severe sequelae of ocular trauma. Prompt intervention is therefore recommended in complex ocular dialyses, and the repair of cyclodialysis clefts and the correction of zonular dialysis can be managed in a combined procedure, involving the insertion of dual CTRs into the ciliary sulcus and the capsular bag.

The datasets generated and/or analyzed during the present study are not publicly available (obtained from Eye and Ear, Nose, and Throat Hospital, Fudan University, Shanghai repository), but are available from the corresponding author upon reasonable request.

ACD：

Anterior chamber depth

BCVA:

Best-corrected visual acuity

CTR：

Capsular tension ring

IOL:

Intraocular lens

IOP:

眼压

logMAR:

Logarithms of the minimal angle of resolution

MCTR:

Modified capsular tension ring

OVD:

Viscosurgical device

UBM：

Ultrasound biomicroscopy

None.

This work was supported by the National Natural Science Foundation of China (grant no. 81770908), the National Key R&D Program of China (2018YFC0116000), and the Shanghai Science and Technology Commission (18411965200).

Affiliations

1. Eye Institute and Department of Ophthalmology, Eye Ear Nose and Throat Hospital, Fudan University, 83 Fenyang Rd, Shanghai, 200031, China

   Jihui Chen，Lina Lan，Yating Tang，Yi Lu＆Yongxiang Jiang

2. NHC近视主要实验室（Fudan University），近视主要实验室，中国医学科学院，上海，200031年，中国

   Jihui Chen，Lina Lan，Yating Tang，Yi Lu＆Yongxiang Jiang

3. Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, 200031, China

   Jihui Chen，Lina Lan，Yating Tang，Yi Lu＆Yongxiang Jiang

贡献

JC analyzed the data and was a major contributor in writing the manuscript. LL and YT participated in data acquisition. YJ and YL supervised and reviewed the manuscript. All the authors have read and approved the final manuscript.

Corresponding authors

Correspondence toYi Luor扬江。

道德批准并同意参加

The Institutional Review Board of the Eye and ENT Hospital of Fudan University, Shanghai, China, approved this study (No.2013021). All procedures were conducted following the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients.

利益争夺

The authors declare that they have no competing interests.

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