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Sci Rep
Sci Rep
Scientific Reports
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10.1038/s41598-024-72715-2
Article
Risk factors for transient ciliochoroidal detachment after goniotomy with the Kahook Dual Blade
Miyako Fumiya
Hirooka Kazuyuki khirooka9@gmail.com

Onoe Hiromitsu
Kiuchi Yoshiaki
https://ror.org/03t78wx29 grid.257022.0 0000 0000 8711 3200 Department of Ophthalmology and Visual Science, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551 Japan
17 9 2024
17 9 2024
2024
14 2172515 2 2024
10 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
To investigate ciliochoroidal detachment (CCD) frequency and risk factors after performing goniotomy with the Kahook Dual Blade (KDB). The presence of CCD was examined using anterior-segment optical coherence tomography at postoperative day (POD) 1, month 1, and month 2 in 91 eyes of patients who underwent goniotomy with KDB. Intraocular pressure (IOP) was also measured at POD 1, POD 7, month 1 and month 2. A generalized linear mixed model analysis was used to compare the age, gender, axial length, central corneal thickness, surgical procedure (combined or single), operators (K.H. or H.O.), glaucoma type and preoperative IOP between the groups. Factors were selected from the variants when there was a probability value of less than 0.05. CCD was detected in 18 eyes (19.7%) at POD 1. For postoperative IOP, no significant differences were observed between the CCD and non-CCD groups. However, the IOP on POD 1 in the CCD that was associated with the anterior chamber group (7.7 ± 3.0 mmHg) was significantly lower than that in the non-CCD group (15.3 ± 0.9 mmHg) (P = 0.02). Mixed-effects model analysis demonstrated that the surgical procedure (combined) and operator (H.O.) were significantly associated with the higher incidence of CCD. Approximately one-fifth of all eyes exhibited CCD after goniotomy with KDB. Combining cataract surgery and goniotomy with KDB and the intraoperative procedure during the goniotomy with KDB were all found to be risk factors for developing CCD.

Keywords

Kahook Dual Blade
Ciliochoroidal detachment
Glaucoma
Subject terms

Diseases
Risk factors
issue-copyright-statement© Springer Nature Limited 2024
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pmcIntroduction

Glaucoma, which is characterized by progressive optic nerve damage and visual field loss, is a complex and chronic ocular condition, with elevated intraocular pressure (IOP) being the central risk factor. In order to treat glaucoma, effective management of IOP is paramount. Furthermore, surgical interventions, such as trabeculotomy (TLO), have also gained prominence in the treatment of these patients. A reduction of the aqueous humor outflow resistance is the goal of TLO, which is accomplished by cleaving the reticular structure of the trabecular meshwork and the inner wall of Schlemm’s canal1. Ab externo trabeculotomy with scleral flap using trabectome is the conventional method used to cleave the trabecular meshwork. However, the introduction of a new technique, the ab interno approach, in which the trabecular meshwork is incised or cleaved by a microhook, the Kahook Dual Blade (KDB) or trabectome, is now becoming the primarily used methodology for these procedures. These minimally invasive glaucoma surgery procedures are generally considered to be less invasive, thereby minimizing the risk of infection, hypotony and scarring2. The trabecular outflow through Schlemm’s canal leading into the episcleral venous system is normally improved after performing the TLO procedure. However, changes in the IOP after the TLO procedure should not be below the episcleral venous pressure (7.6–11.4 mmHg)3. Even so, there have been reports of cases of transient low IOP (less than 5 mmHg) that occur after undergoing TLO4. In addition, this previous study showed that ciliochoroidal detachment (CCD) was related to a low IOP that occurred immediately after a TLO procedure with a trabectome4.

The separation between the ciliary body and the choroid from the scleral wall that occurs during CCD leads to the collection of fluid within the suprachoroidal space. In our previous study, after patients underwent µhook ab interno TLO, we found that CCD occurred in 18 of 62 eyes (29.0%). In addition, there was also a significantly lower IOP in the CCD cases that were connected with the anterior chamber5.

The findings for our current study showed that a thinner central corneal thickness (CCT) was a risk factor for CCD after TLO5. This is in line with the findings of Akagi et al. who also reported finding a thinner CCT in the CCD versus the non-CCD group4. However, at the present time, after TLO, both the nature of the specific etiology and pathophysiology of CCD remain unknown. Therefore, investigations in the current study examined patients after goniotomy with KDB with regard to the incidence rates, potential mechanism and risk factors for CCD.

Results

CCD after goniotomy with the KDB

The clinical characteristics of the 91 eyes of the 71 patients enrolled in this study are presented in Table 1. The mean age was 69.9 ± 13.3 years. At 1 day after undergoing surgery, there were 18 eyes (19.7%) that had 1–3 degrees of CCD (CCD group), while there were 73 eyes that had no CCD (non-CCD group) (Table 2). The grades found at POD 1 include 10 eyes (50%) with grade 1, 5 eyes (27.8%) with grade 2, and 3 eyes (16.7%) with grade 3. In 9 eyes (50.0%) CCD was observed in all quadrants, while 1 eye (5.6%) had CCD in 3 quadrants (nasal, lateral and superior), 1 eye (5.6%) had CCD in 2 quadrants (nasal and superior), and 7 eyes (38.9%) had CCD in one quadrant (nasal). At 1 month postoperatively, there were 7 eyes (38.9%) that remained at grade 1 CCD, while there were 6 eyes (33.3%) that remained at grade 1 at 2 months postoperatively. In our current study, in addition to the CCD, we also observed some adverse events. These included transient IOP elevation (15 eyes) and hyphema (18 eyes). However, no persistent symptoms or any serious side effects, such as infection and hypotony maculopathy were observed. Therefore, we did not perform any procedures for CCD management, such as using cycloplegic drugs or argon laser photocoagulation in cases of CCD.Table 1 Clinical characteristics of study patients.

Age (years)	69.9 ± 13.3	
Gender (M/F)	38/33	
Type of glaucoma	
 POAG	52	
 PACG	9	
 Exfoliation glaucoma	18	
 SOAG	12	
Central corneal thickness (μm)	511.5 ± 36.2	
Axial length (mm)	24.5 ± 3.6	
Surgical procedure	
 Combined	61	
 Single	30	
Preoperative IOP (mmHg)	18.8 ± 7.6	
M male, F female, POAG primary open-angle glaucoma, PACG primary angle closure glaucoma, SOAG secondary open-angle glaucoma, IOP intraocular pressure.

Table 2 Clinical characteristics of study patients with or without CCD at postoperative day 1.

	CCD group (n = 18)	Non-CCD group (n = 73)	P value	
Age (years)	72.1 ± 3.1	69.3 ± 1.6	0.46	
Gender (M/F)	8/10	39/34	0.51	
Type of glaucoma			0.16	
 POAG	8	44		
 PACG	4	5		
 Exfoliation glaucoma	2	16		
 SOAG	4	8		
Central corneal thickness (μm)	507.2 ± 8.6	512.5 ± 4.3	0.61	
Axial length (mm)	24.2 ± 0.9	24.5 ± 0.4	0.74	
Surgical procedure			0.03	
 Combined	17	29		
 Single	1	29		
Operator			0.006	
 K.H	11	67		
 H.O	7	6		
Preoperative IOP (mmHg)	19.3 ± 1.8	18.7 ± 0.9	0.73	
CCD ciliochoroidal detachment, M male, F female, POAG primary open-angle glaucoma, PACG primary angle closure glaucoma, SOAG secondary open-angle glaucoma, IOP intraocular pressure.

The comparisons between the groups with and without CCD for the age, gender, type of glaucoma, CCT, axial length, surgical procedure, operator, and preoperative IOP are presented in Table 2. Multivariable analysis indicated that the cause of CCD was significantly more likely to be associated with the combined cataract surgery (P = 0.03) and the operator (P = 0.01) (Table 3). Furthermore, we investigated whether hyphema was a risk factor for the development of CCD as a postoperative factor. Our results showed that 18 eyes had hyphema on POD 1 (3 eyes in the CCD group, 15 eyes in the non-CCD group). Findings from a generalized linear mixed model demonstrated that hyphema was not a significant risk factor for the development of CCD (P = 0.68).Table 3 Multivariable analysis of factors associated with CCD.

Factors	Multiple generalized linear mixed model analysis	P value	
Odds ratio	95% CI	
Operator (H.O)	7.54	1.70–33.43	0.01	
Surgical procedure (combined)	11.70	1.31–104.75	0.03	
CCD ciliochoroidal detachment, CI confidence interval.

Time course of IOP in eyes with or without CCD

At 2 months postoperatively, there were similar IOP values for the CCD and non-CCD groups (P = 0.07–0.88) (Table 4). A connection between the CCD and the anterior chamber was observed only in the nasal quadrant in the CCD group. This was observed in 6 of 18 eyes (33.3%). Similar IOP values at 2 months after the surgery were observed for both the connection and the non-CCD groups (P = 0.14 → 0.99), with the exception for 1 day after surgery (connection; 7.7 ± 3.0 mmHg, non-CCD; 15.3 ± 0.9 mmHg, P = 0.02) (Table 5).Table 4 Time course of IOP in eyes with or without CCD.

	CCD (n = 18)	Non-CCD (n = 73)	P value	
Preoperative	19.3 ± 1.8	18.7 ± 0.9	0.75	
Day 1	11.6 ± 1.8	15.3 ± 0.9	0.07	
Day 7	20.1 ± 2.0	18.4 ± 0.9	0.46	
Month 1	14.6 ± 1.0	15.7 ± 0.5	0.35	
Month 2	15.3 ± 0.4	15.1 ± 0.9	0.88	
IOP intraocular pressure, CCD ciliochoroidal detachment.

Table 5 Time course of IOP in eyes with connection between the anterior chamber and CCD and without CCD.

	Connection (n = 6)	Non-CCD (n = 73)	P value	
Preoperative	17.8 ± 3.1	18.7 ± 0.9	0.79	
Day 1	7.7 ± 3.0	15.3 ± 0.9	0.02	
Day 7	14.0 ± 2.9	18.4 ± 0.8	0.14	
Month 1	15.3 ± 1.9	15.7 ± 0.6	0.85	
Month 2	15.3 ± 1.6	15.3 ± 0.5	> 0.99	
IOP intraocular pressure, CCD ciliochoroidal detachment.

Discussion

Of the 91 eyes that underwent goniotomy with KDB and were then analyzed in our current study, 19.7% of the cases exhibited an incidence of CCD at POD 1. Other studies that examined CCD after TLO reported finding 14 of 33 (42.4%) eyes had CCD after TLO when using a trabectome4, while 21 of 44 (47.7%) eyes had CCD after they underwent 360° suture TLO6. Furthermore, we also found in our previous study that after µhook ab interno TLO, CCD occurred in 18 of 62 eyes (29.0%)5. The alterations and differences noted in the CCD rate may be associated with the approach and specific instrument used when cleaving open the trabecular meshwork and Schlemm’s canal and then excising it.

While it remains unclear as to how CCD occurs after ab interno TLO, our current study did show that there was a correlation between developing CCD and the surgical procedure type. The development of CCD was more likely in those patients that underwent a combined cataract surgery and goniotomy with KDB. Inflammation, such as Vogt-Koyanagi-Harada disease, could potentially be a cause of CCD7. Although not all of the eyes in our study exhibited severe inflammation, it might be possible that inflammation is greater for combined cataract surgery and goniotomy with KDB as compared to goniotomy with KDB alone. Another possible explanation is that there was alteration of the anterior chamber architecture after lens extraction. To confirm this hypothesis, we will need to further confirm the presence of CCD after cataract surgery alone. Another noteworthy factor regarding the development of CCD was the surgeon’s influence. Our findings showed that one of the surgeons (H.O.) had a higher likelihood of occurrence of CCD versus the other surgeon (K.H.). Strong forces that occur along the longitudinal ciliary muscle can cause cyclodialysis, which can then lead to its separation from the scleral spar8. Therefore, our assumption is that possible complications related to our surgical technique could have led to the creation of an iatrogenic cyclodialysis cleft.

Although we have previously reported that one of the risk factors for developing CCD is a thinner CCT4, our current study did not find that a thinner CCT was a risk factor for developing CCD. Furthermore, Akagi et al. reported finding thinner CCTs in the CCD group as compared to the non-CCD group4. However, they also reported that after goniotomy with KDB, CCT was not a risk factor for developing CCD. While the discrepancies between our current study and the previous studies are hard to explain, it is possible that differences in the device (KDB, microhook, or trabectome) could potentially influence the results. Discussing more about this contradictory consequence, a KDB dissects the trabecular meshwork on the other hand, a microhook trabeculotomy incises it. This difference of procedures may relate to whether thin CCT is a risk factor or not.

Although the present findings did not indicate that there are any differences in the type of glaucoma as a risk factor of CCD (P = 0.16), CCD occurred in a larger proportion in the primary angle-closure glaucoma (PACG) group (56%) as compared to the other types (POAG; 15%, exfoliation glaucoma; 11%, secondary open-angle glaucoma; 33%). While we assume that CCD is more likely to occur in PACG, the number of patients in our current research was too small to definitively detect any significance.

The postoperative IOP values through postoperative month 2 in our current study were similar for both the CCD and non-CCD groups. However, over the short term, we found that there was a significantly lower IOP at POD 1 observed for the eyes with a connection between the anterior chamber and CCD (connection group) as compared to the non-CCD group. Thus, although we did not observe any hypotony (IOP < 5 mmHg) in the current study, closer monitoring and specific considerations might be necessary in cases where the CCD connects to the anterior chamber to avoid developing hypotonic maculopathy, as has been previously reported9.

The CCD group tended to have a higher IOP versus that observed for the non-CCD group’s IOP at 7 days postoperatively. At 1 month postoperatively, the CCD had disappeared in 11 of the 18 eyes. Furthermore, in the 11 eyes in which the CCD disappeared at 1 month postoperatively, it is likely that this would have also disappeared at 7 days postoperatively. Therefore, it is probable that a higher percentage of cases with CCD will have a transient IOP spike after the disappearance of CCD.

At postoperative month 2 in our current study, we found that there were 6 eyes that had CCD. The IOPs were 12, 15, 17, 13, 15, or 15 mmHg, respectively. Ishida et al. evaluated prolonged postoperative CCD and reported finding that this caused persistent hypotony in 4 cases9. The hypotony (IOP < 5 mmHg) in all of these cases was recorded on POD 19. Furthermore, the authors also reported that 2 cases exhibited a shallow anterior chamber, with the depth of the anterior chamber shallower versus the postoperative findings in the other 2 cases9. Although hypotony was recorded in only 1 eye at POD 1 in our current patients, we did not observe any shallow anterior chamber.

Overall, our current findings for patients following goniotomy with KDB underscore the complexity of CCD as a postoperative complication. Therefore, in order to mitigate the risk and effectively manage CCD, there needs to be careful selection of the surgical procedures, surgeon expertise, along with thorough postoperative monitoring also playing a pivotal role. Furthermore, when considering goniotomy with KDB as a treatment option for glaucoma patients, our current results provide valuable insights for ophthalmologists, with an emphasis on the importance of utilizing a personalized approach in order to minimize complications and optimize patient outcomes. In order to more definitively evaluate the underlying mechanisms and long-term implications of CCD within this context, further research is warranted.

It is not clear why CCD occurred in the temporal quadrant. Moreover, cases with CCD in the temporal quadrant had CCD in all quadrants. The IOP on POD 1 was 8.9 ± 2.6 mmHg and 13.6 ± 2.6 mmHg in cases with CCD in all quadrants (9 eyes, 3 eyes had a connection between the CCD and the anterior chamber) and in cases with CCD in 3 or fewer quadrants (9 eyes, 3 eyes had a connection between the CCD and the anterior chamber), respectively (P = 0.23; data not shown). In addition, patients with CCD in all quadrants tended to have a lower IOP. We speculate that the CCD may have occurred in the temporal quadrant as a result of the extreme postoperative decrease in the IOP that was due to the increase in the uveoscleral outflow, and was not an inadvertent procedure that occurred during the surgery. Thus, the onset of CCD may cause further IOP reduction.

In the current study, no significant difference was observed between the CCD group and non-CCD group with regard to the IOP, with the exception of POD 7, and fortunately, there was no hypotony. However, while persistent hypotony cases have been previously reported9, the existence of CCD does not imply there will be a lower IOP over an extended period. Even so, the larger the number of CCD cases, the higher the likelihood of patients developing hypotony. Thus, it is integral that the manipulation of a surgical instrument be as gentle as possible when goniotomy is conducted by KDB, bearing in mind that CCD might be caused by the actual procedure.

It should be noted, however, that the results of our current study need to be taken into consideration in conjunction with potential limitations. First, AS-OCT was not performed prior to any of the surgeries. It has been reported that the preoperative probability of having CCD is very low4,6. Although we were not able to rule out the presence of CCD preoperatively, we consider this to be very unlikely. Second, it should be noted that there was only a very short follow-up period in our current study, with only 6 eyes still exhibiting CCD at postoperative month 2. Furthermore, we did not determine when the CCD actually disappeared in our study. Third, there were only 6 locations where the AS-OCT was performed. Thus, it is possible that we could have overlooked the CCD in areas where the AS-OCT was not performed.

In conclusion, CCD occurred in 18 of 91 eyes (19.7%) after undergoing goniotomy with KDB. Although the postoperative IOP was not significantly different between the CCD and non-CCD groups, when there is connection between the CCD and anterior chamber, there is a risk of developing a low IOP. And finally, since we found that the CCD incidence differed between two surgeons, there is a possibility that the intraoperative peeling of the trabecular meshwork by KDB might have iatrogenically caused the CCD.

Materials and methods

Patients

Between January 2021 and August 2023, glaucoma patients who underwent goniotomy with KDB at Hiroshima University Hospital were retrospectively evaluated. The Institutional Review Board of Hiroshima University approved this study protocol (E2021-2436). All subjects provided written informed consent in accordance with the principles outlined in the Declaration of Helsinki, in addition to standard surgical consent.

With the exception for cataract surgery, all patients who had previously undergone intraocular surgery were excluded from the study analysis. All patients had to be at least 18 years old, in addition to having no history of any other significant ocular disease in order to be able to participate in this current study.

Surgical procedure

For the goniotomy, while using a Hill surgical gonioprism (Ocular Instruments Inc., Bellevue, WA) to visualize the nasal trabecular meshwork, the KDB was intraocularly inserted through a temporal corneal incision. Subsequently, the incision through the nasal trabecular meshwork and the inner wall of Schlemm’s canal (1–5 clock hours in the left eye and 7–11 clock hours in the right eye) was made using the KDB (New World Medical, Inc., Rancho Cucamonga, CA, USA). When patients simultaneously underwent cataract surgery, prior to the goniotomy, a 2.75 mm temporal corneal incision was made for cataract extraction and the intraocular lens implantation.

Patients were instructed to take antibiotics [1.5% levofloxacin (Nipro Corporation, Osaka, Japan)], corticosteroids [0.1% fluorometholone (Santen Pharmaceutical, Osaka, Japan)] and 2% pilocarpine (Santen Pharmaceutical, Osaka, Japan) starting on postoperative day (POD) 1 four times a day for three to four weeks. In patients who had concomitant surgery, nonsteroidal anti-inflammatory drug [nepafenac (Novartis Pharma, Basel, Switzerland)] eye drops were also administered three times a day for 1–2 months. Based on the postoperative IOP, the IOP-lowering medications were then resumed.

Clinical examination

Preoperatively, all patients underwent gonioscopy, slit-lamp examination, IOP measurement with a Goldmann applanation tonometer, and uncorrected and best-corrected visual acuity at 5 m with a Landolt ring optotype. Furthermore, a partial laser interferometer (IOL-master; Carl Zeiss Meditec, Dublin, CA) was used to perform axial length measurements, while a specular microscope (Topcon SP-3000; Topcon Corporation, Tokyo, Japan) was used to obtain the CCT measurements. Follow-up examinations were performed in all patients at days 1 and 7, and at months 1 and 2.

Anterior-segment optical coherence tomography

Anterior-segment optical coherence tomography (AS-OCT) (CASIA2; Tomey, Nagoya, Japan) was used to examine the postoperative CCD. All of the patients were seated and instructed to look contralaterally during the imaging. Three nasal directions, the superior, inferior, and temporal, were examined during the evaluation. In the AS-OCT images, the CCD severity classification was defined based on the maximum value of the CCD that was observed10. The classification grades included: grade 0 (no signs of CCD), grade 1 (slit-like, CCD less than half of the ciliary thickness), grade 2 (banded, CCD greater than half of the ciliary thickness), and grade 3 (obvious, CCD greater than the ciliary thickness) (Fig. 1)10. On POD 1, the CCD and non-CCD groups were defined as being CCD present (grades 1–3) and CCD absent (grade 0), respectively. To determine the presence or absence of CCD, three ophthalmologists (F.M., K.H., H.O.) were masked to the clinical data and then evaluated the AS-OCT images.Fig. 1 Classification of ciliochoroidal detachment. Ciliochoroidal detachment was postoperatively observed. The letter “A” indicates ciliochoroidal detachment.

Statistical analysis

Statistical analyses were conducted using JMP software version 17 (SAS Inc., Cary, NC). A generalized linear mixed model analysis was used to perform the comparisons between the groups for the age, gender, axial length, CCT, surgical procedure (combined or single), operators (H.O. or K.H.), glaucoma type and preoperative IOPs. Factors were selected from the variants having a probability value of less than 0.05. All data are presented as the mean ± standard deviation (SD), with P values less than 0.05 considered to indicate statistical significance.

Acknowledgements

The authors thank FORTE for the English language review.

Author contributions

Data acquisition, F.M.; data analysis and interpretation, F.M., K.H.; figures and tables preparation, F.M.; writing of main manuscript text, F.M.; critical review and revision of the manuscript, K.H., H.O., K.T., Y.K.

Data availability

The datasets generated and/or analyzed during the current study are available from K. Hirooka, the corresponding author, on reasonable request.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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