Cionni-modified capsular tension ring for surgical repair of cyclodialysis after trabeculectomy: a case report

A 64-year-old man complaining of blurred vision was referred to the Eye and ENT Hospital of Fudan University after trabeculectomy of the left eye 3 months earlier. His left visual acuity was 20/2000. Slit-lamp examination revealed corneal edema, a shallow AC, and posterior synechia. The lens was graded C3N3P3 according to the Lens Opacities Classification System III. The shallow AC limited gonioscopic examination. Additionally, fundus examination was not feasible owing to corneal edema and cataract. His IOP was 6 mmHg. B-scan ultrasonography revealed 360 ° choroidal detachment (Fig. 1). Optical coherence tomography (OCT5000, Carl Zeiss Meditec, Dublin, CA, USA) also revealed choroidal detachment and the presence of retinal folds (Fig. 2). Ultrasound biomicroscopy (UBM) (MD-300 L, MEDA, Tianjin, China) was performed and revealed an AC depth of 1.16 mm, 360 ° detachment of the ciliary body, suspected cyclodialysis in the trabeculectomy incision, anterior displacement of the iris–lens diaphragm, and disappearance of the posterior chamber (Fig. 3). Owing to persistent cyclodialysis and dense cataract, the patient was scheduled for surgical treatment of his left eye.

After applying retrobulbar anesthesia, a 2.6-mm superior clear corneal tunnel incision was made. A 0.9-mm-wide paracentesis was performed to insert the chopper. Subsequently, Duovisc (Alcon Laboratories Inc., Fort Worth, TX, USA) was used to maintain the AC, and continuous curvilinear capsulorhexis and hydrodissection were performed. Endocapsular phacoemulsification of the nucleus was performed using the phaco chop technique and cortical aspiration with a Centurion phacoemulsifer (Alcon Laboratories Inc.). Phacoemulsification was performed under a low flow rate with an infusion bottle height of 70 cm. The AC and capsular bag were filled with Duovisc. A foldable IOL was implanted into the capsular bag using an injector cartridge system. The viscoelastic material behind the IOL was removed using a hand-held irrigation/aspiration device. The anterior chamber was refilled with Duovisc. A 13-mm Morcher Type 2 L CTR (Morcher GmbH, Germany), an MCTR with two eyelets preset with 10–0 polypropylene (Alcon Laboratories Inc.), was then inserted into the ciliary sulcus (Fig. 4b). The position of the MCTR was adjusted to aim its maximum focal point at the site of the most severe cyclodialysis after trabeculectomy (Fig. 4c). Two conjunctival periotomies were then performed at the positions of 1 and 2 o’clock from the filtering bleb. The MCTR was sutured with 10–0 polypropylene to the sclera 1 mm posterior to the corneal limbus with one pass at 8:30 o’clock through the eyelet of the CTR and another pass through the 2 o’clock position (Fig. 4d). The suture needle was passed around the interlamellar sclera four times (Fig. 4e). The suture was tightened and cut. The end of the suture was spontaneously retracted to the interlamellar sclera. The residual viscoelastic material was removed (Fig. 4f) and the corneal wound was sutured. Balanced salt solution was injected through the paracentesis to maintain the AC. At the end of surgery, the wound was checked and found to be watertight (Additional file 1: Clip 1).

Postoperatively, the patient was treated with topical 0.1% Tobradex (Alcon Laboratories Inc.) and 0.1% pranoprofen (Sumika Finechem, Osaka, Japan) three times daily for 1 month, followed by weekly tapering.

The patient’s visual acuity improved to 20/400 on the first day after surgery. However, his IOP was 40 mmHg, which decreased after administration of Brinzolamide and Timolol Maleate Eye Drops (Alcon Laboratories Inc.), Brimonidine Tartrate Eye Drops (Allergan Sales LLC), Bimatoprost Ophthalmic Solution (Allergan Sales LLC) twice daily. It is notable that B-scan ultrasonography revealed that the choroidal detachment had disappeared on postoperative day 1 (Fig. 5b). Two months after surgery, his visual acuity was 20/50 and the IOP was 8.2 mmHg. Slit-lamp examination revealed a clear cornea, mild conjunctival congestion, and a deeper AC. UBM 2 months after surgery showed that the AC depth was 3.36 mm, the MCTR was stable in the ciliary sulcus, the IOL was located in the center of the capsular bag, and the cyclodialysis cleft was closed. However, 360 ° shallow ciliary body detachment was evident at 2 months after surgery (Fig. 6a1, a2), but this was absent on UBM performed at 3 months after surgery (Fig. 6b1, b2). At 3 months after surgery, the best-corrected visual acuity was 30/50 with a refractive correction of −1.75DS/−1.00 DC. His IOP had recovered to 16 mmHg. Gonioscopy showed that the cyclodialysis had disappeared. Optical coherence tomography showed that the retinal anatomy was normal at 3 months after surgery (Fig. 7).