07 October 2025: Articles 
Scleral Rupture with Uveal Prolapse Following Trivial Trauma in an Eye Previously Treated with Internal and External Cyclodestructive Procedures: A Case Report
Unusual clinical course, Challenging differential diagnosis, Unusual or unexpected effect of treatment
Raed Alnutaifi ABEF 1,2, Ibrahim Nasser Asiri BDEF 1, Ahmed Al Habash ACD 3, Sami Alshahwan ABDF 4,5, Sulaiman AlTariqi
ADE 4, Halah Bin Helayel ABDEF 1*
DOI: 10.12659/AJCR.949442
Am J Case Rep 2025; 26:e949442
Abstract
BACKGROUND: Scleral rupture and uveal tissue prolapse after internal and external cyclodestructive procedures are rare complications secondary to trivial trauma. Micropulse cyclophotocoagulation (MP-CPC) and ultrasound cycloplasty (UCP) are effective treatments for controlling intraocular pressure (IOP) and pain in refractory glaucoma, with few complications. This case report documents a case of scleral rupture and uveal tissue prolapse secondary to trivial trauma in an eye with a history internal and external cyclodestructive procedures.
CASE REPORT: A 28-year-old woman with a history of intermediate uveitis and secondary glaucoma presented to the Emergency Department with significant eye pain and decreased vision following trivial trauma to her right eye. She had undergone multiple ocular surgeries, including MP-CPC and UCP, 17 months earlier. Examination revealed a perilimbal scleral rupture extending from 2 to 5 o’clock, corneal edema, and hyphema. On the same day as the initial presentation, she underwent primary repair of the right eye. Postoperative recovery showed a gradual improvement in IOP and a stable scleral wound without a leak.
CONCLUSIONS: Following cyclodestructive procedures, structural weakening of the ocular wall may predispose to scleral rupture and uveal tissue prolapse, particularly in eyes with a history of inflammation or prior surgery. Although the rupture in this case was triggered by trauma, it highlights a potential indirect risk associated with such interventions.
Keywords: Prolapse, Rupture, Treatment Outcome, Uveitis, Intermediate, Humans, Female, adult, Sclera, Eye Injuries, Glaucoma, Ciliary Body, Uveal Diseases, Postoperative Complications
Introduction
Glaucoma is a major cause of irreversible visual deterioration, contributing significantly to vision loss worldwide [1,2]. Micropulse cyclophotocoagulation (MP-CPC) diode surgery has become a well-known and effective treatment for controlling intraocular pressure (IOP) and pain in refractory glaucoma. MP-CPC was reported to have a high safety profile and low risk of postoperative complications such as hypotony, anterior chamber (AC) inflammation, scleral thinning, and phthisis bulbi by delivering shorter, repeating energy pulses with rest intervals, in contrast to conventional transscleral CPC, which supplies energy constantly [3]. Similarly, ultrasound cycloplasty (UCP) is a relatively new treatment that uses targeted high-intensity ultrasound to selectively and carefully coagulate the ciliary body while protecting the surrounding ocular tissues [4]. In this case report, we present a rare instance of scleral rupture with uveal prolapse following what the patient described as a trivial, unintentional elbow strike to the eye during play with a sibling – in an eye previously treated with micropulse transscleral cyclophotocoagulation (MP-CPC) and ultrasound cycloplasty (UCP).
Case Report
A 28-year-old woman presented to the Emergency Department with significant eye pain and decreased vision following what she described as trivial trauma that occurred when her younger brother unintentionally struck her right eye with his elbow during play.
Her past ocular history was notable for bilateral secondary uveitic glaucoma and inactive intermediate uveitis since November 2019. She had undergone multiple intraocular surgeries over the years. In the right eye (OD), she first underwent trabeculectomy with mitomycin-C on March 23, 2008, followed by cataract extraction with posterior chamber intraocular lens implantation on October 29, 2008, resulting in pseudophakia. A YAG capsulotomy was performed on July 24, 2016. To manage uncontrolled IOP, she underwent Ahmed glaucoma valve (AGV) implantation with anterior vitrectomy on July 1, 2013. Progressive glaucoma necessitated further intervention with ultrasound cycloplasty (UCP) on October 17, 2018. Despite these measures, IOP remained elevated, and she underwent AGV revision on June 3, 2021 due to tube malposition and an encapsulated plate. Given the refractory nature of her glaucoma, micropulse cyclophotocoagulation (MP-CPC) was later performed on October 31, 2022.
In the left eye (OS), she underwent synechialysis, lens aspiration, anterior vitrectomy, and trabeculectomy with mitomycin-C on December 8, 2009, resulting in aphakia.
Seventeen months after MP-CPC, she presented with eye pain and decreased vision following trivial trauma to her right eye. Her pre-trauma IOP was 9/12 mmHg, and her visual acuity (VA) was 20/25 in the right eye (OD) and 20/50 in the left eye (OS). She had stable conditions characterized by quiet conjunctiva, corneal endothelial dusting, and a flat retina without vitritis or retinitis. However, after the trauma, her VA decreased to hand motion, and her IOP was undetectable.
On examination, she had poor hand motion, a soft hypotonic eye, and significant inferior 270-degree hemorrhagic conjunctival chemosis. The scleral rupture was perilimbal, extending from 2 to 5 o’clock. The tube and trabeculectomy site were both within normal limits (WNL). The cornea was edematous with a 3-mm hyphema, and fibrin was present in the anterior chamber. Additionally, the pupil was mid-dilated and non-reactive. On the same day as the initial presentation, she underwent primary repair of the right eye. A superotemporal paracentesis was made, and viscoelastic was injected into the anterior chamber. A conjunctival peritomy was made from 12 to 6 o’clock. A scleral rupture extending from the 1 to 5 o’clock position was closed using 10 interrupted 9-0 nylon sutures. The conjunctiva was then closed using fibrin glue and 8-0 Vicryl sutures (Figure 1A–1C). Another paracentesis was created for anterior chamber washout of hyphema and viscoelastic devices. The paracenteses were sutured using 10-0 nylon suture.
On the first postoperative day, she had mild tenderness, hand motion vision, and IOP of 6 mmHg. Examination showed mild lid swelling, inferior-temporal and nasal subconjunctival hemorrhage, clear conjunctiva with vicryl sutures, no corneal leak, and a hazy view of the fundus (Figure 2). Additionally, B-scan ultrasonography indicated shallow peripheral choroidal detachment superiorly and nasally (Figure 3). The scleral repair was stable. She was then treated medically with 60 mg oral prednisolone on a weekly tapering regimen and was kept on topical prednisolone acetate 1% hourly and tapered according to the level of inflammation. By the end of the seventh postoperative day, the IOP improved to 17 mmHg, with hand motion vision, a mid-dilated pupil, posterior synechiae, and a stable repair with no leaks observed.
Discussion
LIMITATIONS:
Since this study describes only a single case, its findings are inherently limited in generalizability and cannot establish causation. Although we propose a multifactorial mechanism involving cyclodestructive procedures, prior surgeries, and chronic inflammation, definitive conclusions about direct causality cannot be drawn. Further investigation is needed to validate these associations and inform evidence-based preventive strategies. Moreover, the absence of scleral thickness measurements in this case limits our ability to assess the degree of structural weakening. When feasible, future cases should include anterior segment OCT or ultrasound biomicroscopy to better evaluate scleral integrity.
Conclusions
Following cyclodestructive procedures, structural weakening of the ocular wall can predispose to scleral rupture and uveal tissue prolapse, particularly in eyes with a history of inflammation or prior surgery. Although the rupture in this case was precipitated by trivial trauma, it underscores a potential indirect risk associated with such interventions. Clinicians should remain vigilant when managing high-risk eyes and consider preventive strategies such as optimizing procedural parameters, controlling postoperative inflammation, and educating patients about the risks of trauma to structurally compromised eyes.
Figures
Figure 1. Intraoperative photographs of the right eye showing the extent of scleral rupture and its surgical repair. (A) Perilimbal scleral rupture extending from 1 to 5 o’clock with severe conjunctival chemosis, hyperemia, and uveal tissue prolapse. (B) Close-up view showing corneal edema, fibrin in the anterior chamber, and the irritated conjunctiva around the rupture. (C) Post-primary repair photograph showing the scleral rupture closed with 10 interrupted 9-0 nylon sutures, further stabilized with fibrin glue, and the conjunctiva partially reapproximated with 8-0 Vicryl sutures. 
Figure 2. (A, B) Slit-lamp photograph of the right eye: The black arrows point to the scleral rupture area following primary repair sealed under a bandage contact lens in the presence of secured scleral and conjunctival sutures. 
Figure 3. B-scan ultrasound of the right eye showing mild opacities within the vitreous cavity and organized opacities over the anterior temporal vitreal skirt (highlighted by arrow). No retinal detachment or other intraocular pathology is noted. References
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Figures
Figure 1. Intraoperative photographs of the right eye showing the extent of scleral rupture and its surgical repair. (A) Perilimbal scleral rupture extending from 1 to 5 o’clock with severe conjunctival chemosis, hyperemia, and uveal tissue prolapse. (B) Close-up view showing corneal edema, fibrin in the anterior chamber, and the irritated conjunctiva around the rupture. (C) Post-primary repair photograph showing the scleral rupture closed with 10 interrupted 9-0 nylon sutures, further stabilized with fibrin glue, and the conjunctiva partially reapproximated with 8-0 Vicryl sutures.Figure 2. (A, B) Slit-lamp photograph of the right eye: The black arrows point to the scleral rupture area following primary repair sealed under a bandage contact lens in the presence of secured scleral and conjunctival sutures.Figure 3. B-scan ultrasound of the right eye showing mild opacities within the vitreous cavity and organized opacities over the anterior temporal vitreal skirt (highlighted by arrow). No retinal detachment or other intraocular pathology is noted. In Press
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