Cyclodialysis Clefts following Microinvasive Glaucoma Surgery with Consecutive Intraocular Pressure Spikes

The purpose of this study is to report a case of cyclodialysis clefts associated with microinvasive glaucoma surgery (MIGS) having two distinct consecutive IOP spikes during cleft closure. A 65-year-old female with a history of primary open angle glaucoma was evaluated for right eye blurry vision since cataract surgery 11 months prior. She reported a MIGS procedure that resulted in a cyclodialysis cleft, with resultant hypotony without resolution. On gonioscopy, two clock hours of widened angle were noted nasally, with small clefts (0.5 clock hour) inferonasally and superonasally. Conservative therapy with cycloplegia was unsuccessful. Argon laser photocoagulation was performed for cleft closure. Initially, while there was visible improvement in the cleft size, it did not close completely, and IOP remained low. Additional laser was performed, one week following, she presented with an acute IOP increase to 55 mmHg. On gonioscopy, it was noted that despite the IOP spike indicating inferonasal closure, the superonasal cleft remained small but open. She was started on IOP-lowering therapy. Her IOP normalized shortly thereafter. Two weeks later, she experienced another acute IOP spike to 54 mmHg. On gonioscopy, the residual cleft had closed. Again, her IOP normalized shortly after and has remained normal since. While IOP spikes after cyclodialysis cleft closure have been reported many times, two consecutive IOP spikes of similar magnitude during sequential closure of two concurrent cyclodialysis clefts have not been reported in the literature. This case raises interesting questions about the physiology underlying an acute increase in IOP following cleft closure.