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Ciliary Body Thickness Changes After Preoperative Anti-Inflammatory Treatment in Rhegmatogenous Retinal Detachment Complicated by Choroidal Detachment

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Ciliary Body Thickness Changes After Preoperative Anti-Inflammatory Treatment in Rhegmatogenous Retinal Detachment Complicated by Choroidal Detachment Graefes Arch Clin Exp Ophthalmol DOI 10.1007/s00417-017-3673-2 RETINAL DISORDERS Ciliary body thickness changes after preoperative anti-inflammatory treatment in rhegmatogenous retinal detachment complicated by choroidal detachment Yassine Alibet 1 & Galyna Levytska1 & Nicolay Umanets1 & Natalya Pasyechnikova1 & Paul B. Henrich2,3,4 Received: 26 November 2016 /Revised: 21 February 2017 /Accepted: 4 April 2017 # The Author(s) 2017. This article is an open access publication Abstract body edema (total mean ciliary thickness reduced from 0.83 Background The literature is scant on the state of the ciliary (0.09) to 0.65 (0.09) mm, with a difference of 0.18 (0.07) mm, body, its role in the development of rhegmatogenous retinal P <0.001). detachment (RRD) complicated by choroidal detachment Conclusions Preoperative anti-inflammatory treatment in (CD), and on ciliary body changes following the treatment RRD complicated by CD results in restoration of the anatom- aimed at resolving concomitant inflammation and choroidal ical position of the ciliary body and a statistically significant attachment. This study assesses the anatomical position and reduction in ciliary body edema. thickness of the ciliary body and investigates the ciliary body changes after anti-inflammatory pre-vitrectomy treatment in Keywords Rhegmatogenous retinal detachment . Retinal RRD complicated by CD. detachment . Choroidal detachment . Ciliary body edema . Methods Forty-nine patients (49 eyes) with RRD complicated Triamcinolone acetonide . Perfluoropropane by CD underwent standard ophthalmological examination (in- cluding visual acuity assessment, biomicroscopy, ophthalmos- copy, and ocular tonometry) and ultrasound biomicroscopy of Introduction the ciliary body, choroid, and retina both before and following anti-inflammatory pre-vitrectomy treatment. The prognosis for rhegmatogenous retinal detachment (RRD) Results At baseline, all subject eyes had ciliary body edema complicated by choroidal detachment (CD), marked hypotony and detachment extending into the choroid. Ultrasonographic and intraocular inflammation is rather unfavorable, which is ciliary features included ciliary body edema and disorganiza- confirmed by poor anatomical and functional outcomes of the tion of the supraciliary layer of the pars plana, which was treatment and by high redetachment rates [1, 2]. Therefore, evident by the presence of multiple small oblique fibers. In patients with this form of retinal detachment are usually ex- all subject eyes, the treatment resulted in reattachment of the cluded in multicenter prospective studies of the efficacy of choroid and the ciliary body as well as a reduction in ciliary treatment for RRD [3]. Primary vitrectomy has been recommended for the man- agement of choroidal detachment associated with retinal de- * Paul B. Henrich tachment [4]. It has been reported that administration of oral [email protected] steroids (prednisolone, 1 mg per kg) before primary vitrecto- my in eyes with the disorder improves reattachment rates [5, 1 The Filatov Institute of Eye Diseases and Tissue Therapy AMS of 6]. Preoperative treatment of such eyes with intravitreal injec- Ukraine, Frantsuzkyi Boulevard 49/51, Odessa 65061, Ukraine tions of triamcinolone acetonide (TA), either combined with 2 Department of Ophthalmology, University of Basel, P.O. Box, expansile gases in especially severe cases [7], or alone [6, 8] CH-4012 Basel, Switzerland has a number of advantages. 3 Department of Ophthalmology, Winterthur Cantonal Hospital, The aim of preoperative treatment of such eyes is resolution Winterthur, Switzerland of choroidal detachment and signs of concomitant intraocular 4 Centro Avanti, Lugano, Switzerland inflammation. Anti-inflammatory treatment has been shown to Graefes Arch Clin Exp Ophthalmol also result in a significant decrease in hypotony [5–10], thus Ciliary body thickness (CBT) measurements were per- evidencing the restoration of the function of the ciliary body. formed under cycloplegia with phenylephrine hydrochloride The literature is, however, scant on morphological ciliary 10% and cyclopentolate hydrochloride 1%, at the four cardi- features in combined RRD and CD [11, 12], and, to the best of nal meridians (i.e., the superior, inferior, nasal, and temporal) our knowledge, the changes in the ciliary body following anti- of the eye. Determination of CBT at the pars plana portion in inflammatory treatment have not been investigated. patients with this disease is complicated due to the absence of The aim of the study was to assess the anatomical position well-defined boundaries, presence of multiple small oblique and thickness of the ciliary body and to investigate the ciliary fibers on poorly defined boundaries (Fig. 1) and difficulties in body changes after anti-inflammatory pre-vitrectomy treat- determination of the projection of detached portion of the ment in RRD complicated by CD, intraocular inflammation, ciliary body onto the sclera. Pars plana thickness was also and hypotony. measured at the four cardinal meridians (i.e., the superior, inferior, nasal, and temporal) of the eye (Fig. 2). We recommend measuring CBT in between the ciliary pro- Methods cesses located most closely to the scleral spur (Pat. of Ukraine №105,205, 10.03.2016. Method for determining the ciliary This prospective non-randomized interventional clinical trial body thickness at its detachment. Authors: Levytska G., involved 49 patients (22 men and 27 women; 49 eyes; age, 24 Kovalchuk A., Alibet Y. Owner: State Institution Filatov to 83 years) with RRD complicated by concomitant CD and Institute of Eye Diseases and Tissue Therapy NAMS of intraocular inflammation. Ukraine), since it is at the ciliary process portion of the ciliary Study eyes were treated as per the methodology protocol body that ciliary body boundaries are best defined (Fig. 1). No approved by the ethical committee of the Filatov Institute in significant difference was revealed between the mean CBT 2012 and by the National Academy of Medical Science of values at different locations, P = 0.35. Mean CBT in the four Ukraine 2 years later (Information Bulletin No. 37 of the year meridians in RRD complicated by choroidal detachment be- 2014, p.145, based on Pat. of Ukraine №81,704 issued fore and after preoperative treatment are presented in Fig. 3. 10.07.2013. Method for treatment of rhegmatogenous retinal The difference in mean CBT varied from 0.17 mm to detachment complicated by choroidal detachment. Authors: 0.19 mm, with the SD varying from 0.09 to 0.1 (Fig. 3). Levytska G, Putiienko O, Abdulkhadi M. Owner: State Given no statistically significant difference in the CBT at Institution Filatov Institute of Eye Diseases and Tissue the four cardinal meridians, the changes in the thickness values Therapy NAMS of Ukraine). over time were assessed based on the total mean CBT values. Exclusion criteria were history of previous ocular inflam- We used the Quantel Medical Aviso UBM unit (Quantel matory diseases, ocular trauma or retinal surgery. All patients Medical, Clermont-Ferrand, France) with a 50-MHz linear underwent standard ophthalmological examination including probe (axial resolution: 35 μm; lateral resolution: 60 μm). visual acuity assessment, biomicroscopy, ophthalmoscopy, Patients had ultrasound biomicroscopy performed while posi- and ocular tonometry. Additionally, ultrasound biomicroscopy tioned supine with head-of-bed elevation, both before and 1 to (UBM) of the ciliary body, choroid and retina was performed. 4 days after intravitreal injection. Fig. 1 Ultrasound biomicroscopic measurements. Edematous ciliary body is seen (ciliary body thickness (C1) measured between the ciliary processes located most closely to the scleral spur is 0.79 mm) with poorly defined anterior border of pars plana ciliaris and multiple small oblique fibers. The pars plicata is adherent to the sclera while the pars plana is detached along with the detached choroid Graefes Arch Clin Exp Ophthalmol Fig. 2 Ultrasound biomicroscopy images showing the ciliary body before (left side) and 1 day after (right side) treatment with intravitreal injection of 4 mg of triamcinolone acetonide in combination with perfluorpropane. Pretreatment (left side) images at the superior (a), nasal (b), inferior (c), and temporal (d) meridians show edematous and detached ciliary body with multiple small oblique fibers on diffuse outer boundaries; the detachment extends into the choroid. Post-treatment (right side) images at the same meridians show reduced ciliary body edema and complete attachment of the ciliary body. Additionally, triamcinolone acetonide crystals and opacities are well differentiated against the crystal background in the vitreous cavity (arrow 1). The gas bubble is localized in the scans taken in each of the meridians (except the scan taken in the inferior meridian) Prior to vitrectomy, under the above-mentioned cycloplegic eyes) or in combination with 0.4 to 0.8 mL of perfluorpropane conditions and following preoperative topical treatment with until IOP became normotensive (19 eyes). This treatment 0.1% dexamethasone and cyclopentolate hydrochloride 1% aimed at preoperative resolution of choroidal detachment and eye drops, study eyes received anti-inflammatory therapy, with intraocular inflammation to decrease the risk of intra- and post- 4 mg of (0.1 mL) TA intravitreally injected either alone (30 operative complications in retinal detachment surgery. Graefes Arch Clin Exp Ophthalmol Fig. 3 Ciliary body thicknesses in the superior
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