Ocular Hypotony Workup

  • Author: Sheila P Sanders, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 9, 2010
 

Laboratory Studies

  • Hypotony is usually diagnosed based on only the history and the physical examination.
  • In patients with undiagnosed but suspected uveitis, evaluate for systemic inflammatory disease, especially if the condition is recurrent.
  • In patients with suspected temporal arteritis, measure C-reactive protein and erythrocyte sedimentation rate.
  • In patients with bilateral hypotony, test for glucose, blood urea nitrogen, and creatinine.
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Imaging Studies

Determining if the etiology is predominantly increased outflow or decreased inflow helps to establish treatment approaches.

  • Ultrasonic biomicroscopy or anterior optical coherence tomography (OCT) can help to further evaluate the anterior chamber depth, the position of the ciliary body, and the presence of anterior ciliary detachment, cyclitic membrane, or cyclodialysis cleft. OCT of the posterior pole can help to better demonstrate subtle macular fluid or folds and follow progression over time.
  • Fluorescein angiography is useful in helping to distinguish retinal folds from choroidal folds.
  • Intraoperatively, the ciliary body can be directly visualized to evaluate rotation and traction using endoscopy.[2]
  • B-scan ultrasonography is especially useful when the fundus is not easily visualized. It can help in determining the size and the extent of ciliochoroidal detachment, choroidal hemorrhage, and retinal detachment. An example is shown in the image below. B-scan ultrasound of choroidal effusions before anB-scan ultrasound of choroidal effusions before and after surgical drainage.
  • Ultrasound studies of the carotid arteries are recommended for patients with suspected ocular ischemia.
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Other Tests

  • Wound leaks can be identified using the Seidel test.
    • Concentrated fluorescein on a paper strip is preferable to topical fluorescein/anesthetic solution.
    • The slit lamp is set to blue light, and the paper is stroked over the surface of the eye.
    • Aqueous humor escape can be detected as spots of brighter yellow that slowly expand. Gentle pressure on the globe may be required to detect subtle leaks.
    • Wound leaks with overlying intact conjunctiva cause filtering blebs and remain Seidel negative.
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Contributor Information and Disclosures
Author

Sheila P Sanders, MD  Associate Professor, Director of Glaucoma Service, Department of Ophthalmology, University of Kentucky College of Medicine

Sheila P Sanders, MD is a member of the following medical societies: American Academy of Ophthalmology and American Glaucoma Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Bradford Shingleton, MD  Assistant Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary

Bradford Shingleton, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

J James Rowsey, MD  Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Fannin LA, Schiffman JC, Budenz DL. Risk factors for hypotony maculopathy. Ophthalmology. Jun 2003;110(6):1185-91. [Medline].

  2. Hammer ME, Grizzard WS. Endoscopy for evaluation and treatment of the ciliary body in hypotony. Retina. Feb 2003;23(1):30-6. [Medline].

  3. Ugahary LC, Ganteris E, Veckeneer M, Cohen AC, Jansen J, Mulder PG, et al. Topical ibopamine in the treatment of chronic ocular hypotony attributable to vitreoretinal surgery, uveitis, or penetrating trauma. Am J Ophthalmol. Mar 2006;141(3):571-3. [Medline].

  4. Aminlari A, Callahan CE. Medical, laser, and surgical management of inadvertent cyclodialysis cleft with hypotony. Arch Ophthalmol. Mar 2004;122(3):399-404. [Medline].

  5. Sarkisian SR Jr. Tube shunt complications and their prevention. Curr Opin Ophthalmol. Mar 2009;20(2):126-30. [Medline].

  6. Budenz DL, Chen PP, Weaver YK. Conjunctival advancement for late-onset filtering bleb leaks: indications and outcomes. Arch Ophthalmol. Aug 1999;117(8):1014-9. [Medline].

  7. Fine HF, Biscette O, Chang S, Schiff WM. Ocular Hypotony: A Review. Comprehensive Ophthalmology Update. Jan-Feb 2007;8:29-37.

  8. Haynes WL, Alward WL. Control of intraocular pressure after trabeculectomy. Surv Ophthalmol. Jan-Feb 1999;43(4):345-55. [Medline].

  9. Hsu J, Chen E, Gupta O, Fineman MS, Garg SJ, Regillo CD. Hypotony after 25-gauge vitrectomy using oblique versus direct cannula insertions in fluid-filled eyes. Retina. Jul-Aug 2008;28(7):937-40. [Medline].

  10. Kunimoto DY, Kenitkar KD, Makar M. Hypotony. In: The Will's Eye Manual. Lippincott, Williams, & Wilkins; 2004:440-442.

  11. Migdal C, Hitchings R. Morbidity following prolonged postoperative hypotony after trabeculectomy. Ophthalmic Surg. Dec 1988;19(12):865-7. [Medline].

  12. Nicolela MT, Carrillo MM, Yan DB, Rafuse PE. Relationship between central corneal thickness and hypotony maculopathy after trabeculectomy. Ophthalmology. Jul 2007;114(7):1266-71. [Medline].

  13. O'Connell SR, Majji AB, Humayun MS, de Juan E Jr. The surgical management of hypotony. Ophthalmology. Feb 2000;107(2):318-23. [Medline].

  14. Pederson J. Ocular hypotony. In: Duane's Clinical Ophthalmology. Vol 3. 1993.

  15. Ritch R, Shields MB, Krupin T. Ocular hypotony. In: The Glaucomas. Vol 3. 1996:385-395.

  16. Roters S, Szurman P, Engels BF, Bartz-Schmidt KU, Krieglstein GK. Ultrasound biomicroscopy in chronic ocular hypotony: its impact on diagnosis and management. Retina. Oct 2002;22(5):581-8. [Medline].

  17. Schubert HD. Postsurgical hypotony: relationship to fistulization, inflammation, chorioretinal lesions, and the vitreous. Surv Ophthalmol. Sep-Oct 1996;41(2):97-125. [Medline].

  18. Suner IJ, Greenfield DS, Miller MP, Nicolela MT, Palmberg PF. Hypotony maculopathy after filtering surgery with mitomycin C. Incidence and treatment. Ophthalmology. Feb 1997;104(2):207-14; discussion 214-5. [Medline].

  19. Walker SD, Brubaker RF, Nagataki S. Hypotony and aqueous humor dynamics in myotonic dystrophy. Invest Ophthalmol Vis Sci. Jun 1982;22(6):744-51. [Medline].

 
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Seidel-positive wound leak around a conjunctival suture.
Conjunctival advancement flap sewn over a diffusely incompetent bleb.
Eroded tube shunt in a patient with rheumatoid arthritis.
Flat anterior chamber with iris-corneal touch following a phacotrabeculectomy.
Autologous blood injected into an overfiltering bleb to create a blood patch.
B-scan ultrasound of choroidal effusions before and after surgical drainage.
 
 
 
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