AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

In pseudophakic pupillary block, the implanted intraocular lens (IOL) is partly or wholly involved in the obstruction of the aqueous flow through the pupil. This condition can develop days, weeks, months, or years after the lens implant surgery. If the condition is not recognized and treated early, it can lead to iris bombe, iridocorneal adhesion formation (starting at the periphery and extending toward the center), increasing intraocular pressure (IOP), and progressive damage to the optic nerve head.

The block is caused via mechanical closure of the pupil by the optic of the pseudophakos or by the development of synechiae between the iris and the artificial lens or remaining lens capsule. Pseudophakic pupillary block also can occur in patients with anterior chamber IOLs, either by direct blocking of the pupil by the optic or by the development of adhesions between the vitreous and the posterior iris. Closure of an existing peripheral iridectomy or an absence of a peripheral iridectomy may be a precipitating factor.

Pathophysiology

Extracapsular surgery that precedes the insertion of the IOL creates the following conditions that are conducive to inflammatory, proliferative, and fibrotic reactions: retention of a large part of the anterior lens capsule, retained lens matter in the fornices of the capsular bag, a tear of the posterior capsule, and lens-vitreous mix. The inflammatory reactions produce adhesions between the artificial lens and the uveal tissues, particularly the iris.

The so-called sulcus-supported lenses have a tendency to erode the ciliary processes and the ciliary body. In the process, a breakdown of the blood-aqueous barrier occurs. The optics of the sulcus-supported lenses have a greater tendency to partial or complete pupillary capture. The fibrous reactions in the capsular bag also can push the optic out of the bag, a process that may lead to the pupil capture.

Either of the following can push the lens optic firmly against the pupil, effectively blocking the forward movement of the aqueous and causing partial or complete pupil capture: the shallowness of the anterior chamber due to a wound leakage or pooling of aqueous in the vitreous pushing the lens optic forward.

In pediatric patients, the aforementioned factors play a part with much greater severity than in adults. Fibrin formation is encountered more often in children. There is a greater tendency for the optic to come out of the small capsular bag and become captured by the pupil. In neonates and young infants, there is a tendency for the iridectomy opening to shrink (like shrinkage of a continuous curvilinear capsulorrhexis) and ultimately close.

The net result of all these processes is iris bombe, anterior synechiae formation, glaucoma, and an increased resistance to the forward movement of the aqueous. Pupillary block can occur if the peripheral iridectomy and the pupil close by the above factors and one of the following is used: an IOL in the anterior chamber, an angle-supported lens, or an iris claw (Artisan) lens. In the pupillary area, the initial adhesions are formed between the pupil and the posterior capsule. As iris bombe develops, adhesions form between the anterior surface of the iris and the optic and the haptic of the IOL. The iris bombe may involve the whole iris; more often, it is multiloculated.

Frequency

International

Pseudophakic pupillary block is not an uncommon condition. The exact incidence is not known, but it occurs more frequently in pediatric patients, especially those who are very young.

Mortality/Morbidity

Failure to relieve the pupillary block can lead to the development of chronic angle closure glaucoma and glaucomatous optic neuropathy.

Race

No predominance in specific races exists; however, Nd:YAG laser iridotomy may be difficult to perform in dark-skinned people.

Sex

No sexual predilection exists.

Age

The younger the patient, the greater the chance of a pseudophakic pupillary block. The space behind the iris contains the following reactive elements: anterior and equatorial lens capsular cells, remains of lens matter, ciliary processes and ciliary body, and posterior pigment epithelium of the iris. These elements can trigger inflammatory, proliferative, and fibrotic responses in the pupillary area and around the IOL. This ultimately can result in a pseudophakic pupillary block. Such reactions are uncommon in adults, especially after implantation in the bag. In the presence of an anterior chamber angle-supported lens or an iris claw lens, the absence or the closure of a peripheral iridectomy usually initiates the pupillary block.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

Problems begin after a variable period of days, weeks, months, or years after the operation.

• Patients with pupillary block glaucoma usually note the sudden onset of symptoms, to include the following:
• • Pain in the affected eye
  • Unilateral headache
  • Blurred, steamy vision
  • Photophobia
  • Haloes around lights
  • Intense redness
  • Nausea and vomiting (sometimes)
• In adults, deteriorating vision and increasing discomfort and pain are noticed and reported.
• The onset of this condition usually is rapid in pediatric patients, but it also can be insidious.
• • In the case of very young patients, parents notice a vacant look, a squint, and an inability to hold an object with the operated eye. They might notice pupillary changes in color and size and eye redness. The child frequently rubs the eye, refuses food, cries, and does not sleep soundly. The child might vomit for no obvious reason.
  • Older children report decreased vision and heaviness or pain in the eye.

Physical

A complete eye examination should be performed. Visual acuity usually is reduced depending upon the amount of corneal edema induced by the high IOP.

• Pupillary examination
• • Various inflammatory and fibrotic forces may deform the pupil. The pupillary capture and decentration of the lens optic may further affect its shape.
  • High IOP may damage the pupillary sphincter, leading to a mid-dilated, nonreactive pupil. An afferent pupillary defect would not be expected immediately.
  • Blood, fibrin, Elschnig pearls, or thin or thick opaque fibrous membrane formation may cloud the pupil transparency.
• Slit lamp examination
• • Conjunctival injection with a circumlimbal flush is observed.
  • The incision line might show iris incarceration, a sign of earlier leakage.
  • Varying degrees of corneal edema and striae may be present from the elevated IOP. Endothelial debris may be present depending upon the degree of inflammation.
  • The anterior chamber is shallow in the periphery but deeper centrally. Peripheral anterior synechiae (PAS) are evident. Iris bombe may be uniform or loculated. Iris atrophy may be present in areas where the lens optic impinges. Sites of erosion of the iris by the lens loops or the optic may be present.
  • The optic of the posterior chamber lens may be seen partially or completely captured by the pupil. One or two loops may be seen, which erode the pupillary margin. Pigment, exudates, foreign body giant cells, or an amorphous inflammatory or a noninflammatory membrane on the surface of the visible lens surface may be present.
  • If a peripheral iridectomy was performed previously, it may not be seen. It may be closed by blood or fibrin, or the area of the iridectomy may be scarred or closed with exudates or posterior adhesions with the lens capsule. Elschnig pearls, lens matter, or blood also can block the iridectomy. It can close if the adjacent iris becomes incarcerated in the incision line.
• IOP: Normal in very early cases, but IOP rapidly rises as the condition advances. IOP in excess of 50 mm Hg is not unusual.
• Gonioscopy
• • Cornea edema may not permit gonioscopy. When possible, it will show angle closure. If the process is long-standing, PAS may be visible.
  • Slit lamp examination may show iridocorneal adhesions.
  • Aqueous flare, cells, pigment, and exudates are seen.
• Fundus examination: This examination may not be possible because of corneal edema. Usually, cupping is not evident until the IOP rise is long-standing. Sudden rises in IOP may cause pulsations in the central retinal artery and, if seen, should prompt emergent lowering of the IOP.

Causes

Risk factors for postoperative pupillary block include diabetes; short (axial length) eyes; and complicated surgical procedures preventing placement of the IOL in the capsular bag, including torn or disinserted posterior capsules; and vitreous loss. Poor capsular support may allow subluxation of the IOL with subsequent blockage of the pupil by vitreous, while placement of the IOL in the ciliary sulcus may allow for increased contact between the lens optic and the pupil. Placing an IOL upside down also may lead to pupillary block since most lenses are vaulted posteriorly; placing it upside down will force the optic anteriorly toward the pupil. Use of an undersized anterior chamber IOL may allow the optic to fall into the pupil, thereby creating block.

• Inflammation
• • Acute inflammation can cause rapid occlusion of the pupil and the peripheral iridectomy with exudates.
  • Subacute and chronic inflammation may produce gradual formation of adhesions between the iris and the optic of the IOL, as well as the remaining capsular bag.
• Physical blockage of the pupil may occur from many materials, including the following:
• • Blood
  • Fibrin
  • Vitreous
  • Lens material
  • Wound leak (may cause shallowing of the anterior chamber, allowing the IOL optic to move forward)
• Proliferative
• • Elschnig pearls blocking the peripheral iridectomy
  • Elschnig pearls closing the space between the iris and the IOL
• Fibrotic changes - Formation of thick membrane in the pupillary area
• A combination of the above factors may cause this condition.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Choroidal hemorrhage
Aqueous misdirection
Pupil capture

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Blood sugar
• Clotting and bleeding time

Imaging Studies

• B-scan
• • Routine B-scan helps to identify the presence of a fallen nucleus, retained cortical matter, blood, and exudates in the vitreous.
  • Usually, choroidal hemorrhages can be seen easily.
  • A high-quality B-scan may identify anterior movement of the posterior vitreous compatible with aqueous misdirection.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Medical treatment for acute pupillary block is designed to lower IOP, to quiet the eye, and to clear corneal edema, thereby allowing visualization for peripheral iridectomy.

• Analgesics may be administered as necessary. Antiemetics also may be necessary if nausea and vomiting are problematic.
• To control IOP, immediate treatment includes topical beta-adrenoreceptor antagonists (beta-blockers), alpha2-agonists, and carbonic anhydrase inhibitors.
• • Acetazolamide may be administered by mouth or, if the patient is nauseous and vomiting, by 500 mg IV push.
  • Intravenous or parenteral hyperosmotics (1 g/kg of body weight) may effectively lower IOP immediately but transiently. Available agents include glycerin and isosorbide solution 45% weight/volume (ismotic) for oral use or mannitol (ie, 100 g in 500 cc IV drip, 12.5 g in 50 cc IV push) for intravenous administration.
• Dilatation of the pupil may help relieve pupillary block in pseudophakia or break posterior synechiae.
• Inflammation accompanying acute angle closure may be treated with topical steroids, adjusting the dosage as needed to quiet the eye.

Surgical Care

The definitive procedure to break pupillary block is a peripheral iridectomy. This procedure usually can be accomplished using a laser (Nd:YAG, argon, or both), but, sometimes, in the case of severe inflammation, a surgical iridectomy may be necessary. Every attempt should be made to medically control IOP and to clear corneal edema before performing a laser iridectomy. Severe cases with membrane formation, nonclearing blood or inflammatory debris, or subluxed IOLs may require intraocular manipulation.

• Peripheral iridectomy
• • A single peripheral iridectomy may be sufficient to break the block and to relieve the problem.
  • Multiple iridectomies may be necessary if multiple pockets of trapped aqueous are present behind the iris. This may be due to vitreous adherent to the iris or synechiae to the posterior capsule.
  • Laser iridectomies in inflamed eyes may be at risk for closure. If this is the case, they may be reopened or performed at another site. Surgical iridectomy may be more successful in such cases.
• Freeing the pupil
• • Breaking iris-IOL synechiae
  • Removing inflammatory or fibrotic membranes
• Removal of obstructive elements
• • Blood
  • Lens matter
  • Elschnig pearls
  • Vitreous
  • Inflammatory exudates
• Vitrectomy may be necessary to remove vitreous from the anterior segment of the eye.
• Manipulation of IOLs
• • Repositioning of IOLs
  • Explantation
  • Exchange
• Filtration surgery
  • Filtration surgery is indicated if the anterior chamber angle fails to open following iridectomy, indicative of synechial closure, and IOP remains uncontrolled despite maximum tolerated medical therapy.
  • Transciliary filtration can relieve iris bombe expeditiously. It connects the posterior chamber to the subconjunctival space. The filtration track is made with the Fugo blade.

Activity

The relief of symptoms and the resulting visual function determines the return to normal activity. Generally, no limitation of activity is required following laser iridectomy. If filtration surgery is required, limitation of activity may be necessary for 7-10 days.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Patients with pseudophakic pupillary block may experience sudden and prolonged increases in IOP. As soon as the patient presents with this condition, the greatest concern is to lower IOP as quickly as possible. The near normalization of ocular tension reduces operative and postoperative risks. Almost all glaucoma medications may be used (see Glaucoma, Primary Open Angle), including beta-blockers and alpha2-agonists, but miotics should be avoided. In addition, acetazolamide (a carbonic anhydrase inhibitor) and mannitol (a hyperosmotic agent) may be required; analgesics and steroidal and nonsteroidal medicines also may be needed. Postoperative medicines depend on the progress; in most cases, it is the instillation of antibiotic-steroid and antiglaucoma drops.

Drug Category: Carbonic anhydrase inhibitors

By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit carbonic anhydrase in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.

Drug Category: Hyperosmotic agents

Hyperosmotic agents lower IOP by moving fluid out of the vitreous into the blood stream. Cannot be used chronically due to the risk of dehydration and electrolyte imbalance (particularly hypokalemia). Mannitol is a highly effective medicine of this group. Given intravenously and highly suitable for patients with nausea and vomiting caused by severe rise in the IOP. Extremely useful for administration just prior to the surgery. Glycerine is a nontoxic, readily available hyperosmotic agent, to be administered by mouth, to tide over a period of crisis. Isosorbide is an important hyperosmotic agent that can be given safely to patients with diabetes.

Drug Category: Cholinergics

Help treat iris bombe by breaking iris IOL adhesions. Useful only in early cases. Once firm adhesions have been formed, it is difficult to break them by local medication.

Drug Category: Sympathomimetic agents

When combined with parasympatholytics, provide the best chance of dilating the pupil.

Drug Category: Corticosteroids

Inflammation is a constant accompaniment of patients with pseudophakic pupillary block. Steroid drops are very effective in reducing intensity of inflammation. Steroids control practically all aspects of the inflammatory process and immune response. Their main activity occurs at the actual site of inflammation; therefore, topical application in the eye suppresses inflammation.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

• Regular, prolonged follow-up care is needed to observe and preserve the normal anatomy of the anterior segment, the clarity of the refractive media, and the maintenance of normal IOP. Monitoring of visual fields and visual acuity also is important.
• Pediatric patients need special care during the postoperative period. They may need sedation or even general anesthesia for a proper and thorough examination.
• Examine for uveitis by performing a careful slit lamp examination at every visit. In particular, examine for the presence of aqueous flare and cells and deposits on both the corneal endothelium and the optics of the IOL.
• • The position of the IOL is monitored for centration of the optic, deposition of pigment or foreign body giant cells, and any adhesions that may be developing with the iris.
  • Lifelong, regular follow-up care is important. Explain at every visit the current status of the eye. Strongly advise the patient to come for regular check-ups after 1, 2, or 3 months or longer (as the situation demands).

In/Out Patient Meds

• Local and systemic medication depends on both the condition and the needs of a particular patient.
• • Most of the operated cases generally need mydriatics, anti-inflammatory medications (steroidal and nonsteroidal), and antiglaucoma medicines.
  • The frequency of local instillation, the dose of oral medication, and the length of medication are determined by the needs of the individual patient.

Transfer

• An experienced surgeon and adequate facilities must be available to manage these patients. If not available, transfer of the patient is warranted.

Complications

• Patients with glaucoma who are untreated or poorly treated experience loss of visual acuity and visual fields, which may result in total visual loss.
• Corneal decompensation may result from endothelial damage caused by the sudden rise in IOP or prolonged uncontrolled IOP. It also may result from contact with an anteriorly displaced IOL.
• Uveitis may result from iris and/or ciliary irritation from the IOL or vitreous, as well as breakdown of the blood-aqueous barrier due to acute glaucoma. Surgery may lead to prolonged inflammation.
• Chronic inflammation and/or vitreous in contact with the iris may lead to the development of cystoid macular edema with reduced visual acuity, even after the IOP problem has been corrected.

Prognosis

• The earlier the condition is detected and adequately treated, the greater the chance of a full recovery. Once it is found that the pupillary block is not amenable to conservative treatment and an early surgical correction is instituted, the chances of recovery are excellent.

Patient Education

• All patients undergoing intraocular surgery should be advised to contact the surgeon immediately if they experience pain or sudden decreases in vision in the postoperative period. These signs could indicate the development of pupillary block and acute glaucoma.
• Patients should be aware of the need for regular follow-up visits to detect such problems before they result in serious vision-threatening conditions.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to identify iris bombe, closed peripheral iridectomy, raised IOP, erosion of the iris by lens loops, and partial or complete pupil capture
• Failure to monitor closely and/or to provide prompt medical or surgical intervention to reestablish normal aqueous circulation
• Nonreferral to a better equipped center when the facility does not have an Nd:YAG laser or the equipment to perform a peripheral iridectomy
• Failure to diagnose and manage a leaking anterior chamber
• Failure to identify and manage retained lens matter
• Failure to surgically manage disturbed vitreous in the anterior chamber with a vitrectomy instrument
• Failure to obtain a B-scan in the event of nonvisibility of the fundus
• Failure to examine a noncooperative pediatric patient under general anesthesia, which could help diagnose and treat the condition in the earlier stages
• Failure to inform the patient about the serious nature of the development and the need for regular follow-up visits (even after proper management)

Special Concerns

• Pediatric patients
• • To ensure early detection and management of pupillary block, pediatric patients who have undergone the following procedures require frequent checks for the first 6 months after surgery: lens implantation for a congenital cataract, a traumatic cataract, or aphakia.
  • One approach is to perform an anterior vitrectomy in every pediatric case. The other (perhaps more sensible) approach is to regularly observe these patients and to perform a laser or surgical intervention only when needed.
  • If the parents express total inability to return for regular follow-up visits, it may be better to perform a medium-size peripheral iridectomy. It is also reasonable to perform a small or medium anterior vitrectomy in case the posterior capsule is opaque.
• Patients with diabetes
• • Since patients with diabetes are more prone to develop pupillary block (due to adhesion formation between the lens optic and the iris), it may be acceptable to perform a peripheral iridectomy at the time of primary operation.
  • Weigh the advantage of iridectomy against the tendency for patients with diabetes to bleed.
• Postinflammatory and traumatic cataracts: Since this group of patients has greater chances of pseudophakic pupillary block, they may require more frequent follow-up visits (eg, 1-2 mo for the first 6 mo and less frequently thereafter).
• Corneal endothelium
• • The corneal endothelium undergoes a grievous loss by wide peripheral and mid-peripheral endothelium-iris touch, increased IOP, and uveitis.
  • Examine these patients at least twice a year for cell counting by specular endothelial microscopy.
• Visual fields and visual acuity: Increased IOP for days, weeks, or months requires a thorough examination of the visual acuity and the visual fields; perform this examination as soon as possible after the corrective surgery.
• IOP: Check regularly and take appropriate steps to treat glaucoma.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Pseudophakic pupillary block precipitated by leakage of the incision line. This led to a chain reaction of forward movement of the posterior chamber lens, closure of the angle, intractable glaucoma, and iris-cornea touch over a wide area.
	View Full Size Image
Media type:  Photo

Media file 2:  Same patient as in Image 1, 1 month after surgery. She underwent iridectomy at 3 places, separation of the iris from the cornea and the optic of the intraocular lens with viscoelastic material, and ab-interno filtration procedure at the 6-o'clock position, with erbium laser. The intraocular pressure is 13 mm Hg.
	View Full Size Image
Media type:  Photo

Media file 3:  Pupillary block in the presence of a posterior chamber lens. This stereo pair shows the closure of the peripheral iridectomy, dilated pupil, iris lens adhesions, and fibrotic membrane formation in the whole of the pupillary area. A large area of the iris shows iris bombe formation.
	View Full Size Image
Media type:  Photo

Media file 4:  This 5-year-old child, a case of congenital cataract, earlier had pupillary block and moderate iris bombe, which was relieved by 2 shots of Nd:YAG on the ballooned iris and the peripheral iridectomy opening. Two weeks later, he came back with a much worse pseudophakic pupillary block and multiloculated ballooning of the iris. The intraocular pressure was raised. Pigment and exudates were on the surface of the intraocular lens. Thecondition was relieved by reopening the peripheral iridectomy site, removing the posterior capsule in the pupillary area; performing iridectomy along the upper pupillary margin, a small central anterior vitrectomy and cleaning the intraocular lens with the help of a vitrector. The anterior chamber wasdeepened with a large air bubble. The recovery was uneventful.
	View Full Size Image
Media type:  Photo

Media file 5:  One month postoperatively, the cornea was clear, the anterior chamber was deep, a few peripheral anterior synechiae were present, the pupillary area was clear, the pigment on the periphery of the intraocular lens had been reduced, the intraocular pressure was normal, and corrected visualacuity was 20/80. The patient remained free from a pupillary block thereafter.
	View Full Size Image
Media type:  Photo

Media file 6:  Pseudophakic pupillary block observed in a case of posterior chamber lens. The pupil is closed and deformed by the optic of the lens and the fibrous tissue, but the consequences of pupillary block are missing due to the presence of a patent peripheral iridectomy.
	View Full Size Image
Media type:  Photo

Media file 7:  The patient is 6 years old. Closure of peripheral iridectomy, lens decentration, partial pupil capture, and adhesions between the optic and the iris have produced pupillary block. One of the loops has started cheese-wiring the iris. Iris bombe is all around. Iris incision line adhesions are visible. The intraocular pressure is normal.
	View Full Size Image
Media type:  Photo

Media file 8:  With the help of a vitrector, the central part of the iris has been moved over and close to the optic. No attempt has been made to reposition the optic of the lens. The peripheral iridectomy is left as such. The iris bombe has settled nicely.
	View Full Size Image
Media type:  Photo

Media file 9:  Pediatric iris claw lens implantation, showing a pupillary block that has been precipitated by the closure of the peripheral iridectomy with Elschnig pearls. The pupil has been closed with the optic of the lens. A vertical fibrotic band courses vertically across the edge of the optic. The 360o iris bombe has encouraged adhesion formation between the iris and the perimeter of the lens. Treatment in these cases involves removing Elschnig pearls, opening and enlarging the existing iridectomy, making an additional iridectomy elsewhere, cutting the fibrous band, separating the iris from the optic, doing a small anterior vitrectomy, and enlarging the pupil with a vitrector toward the 12-o'clock position (so that the edge of the pupil goes beyond the edge of the optic).
	View Full Size Image
Media type:  Photo

Media file 10:  The stereo pair shows pseudophakic pupillary block in a brown eye. No peripheral iridectomy is visible. The pupil is dilated, and the iris is adherent to the optic of the lens. An amorphous, translucent membrane is present on the surface of the lens. The treatment involves a surgical iridectomy, clearing the optical axis of any obstacle, and performing a small anterior vitrectomy.
	View Full Size Image
Media type:  Photo

Media file 11:  A 60-year-old patient with a light-colored iris presents with pseudophakic pupillary block. Lens implant surgery was performed 6 months ago. The pupil is dilated moderately. There are adhesions with the optic of the posterior chamber lens. One loop of the lens is pushing itself into the anterior chamber. Iris bombe is seen in 360º. Most of the iris from the 6-o'clock position to the 11-o'clock position is in contact with the endothelium. A round continuous curvilinear capsulorrhexis is visible, in front of which the optic of the lens lies. The patient has been experiencing eye aches for 2 months. Intraocular pressure is 35 mm Hg. A filtration operation for glaucoma with 1 or 2 iridectomies suffices for control of glaucoma and for clearing the pupillary block. Further intervention depends on the progress of the case.
	View Full Size Image
Media type:  Photo

Media file 12:  A 56-year-old patient presents with a 4-loop-angle-supported lens. Two loops are visible, while the other loops are hidden under the iris tissue. From the 10-o'clock position to the 3-o'clock position, the edge of the optic is hidden under the overgrown iris tissue. A translucent membrane, 4-cornered in shape, is adherent to the anterior surface of the optic. A peripheral iridectomy is not visible. The pupil is blocked with pigment and scar tissue. The optic of the lens is acting like a perfect lid over the pupil. Iris bombe is all around, more so in the upper half. The endothelial cell count is 1700 cells/mm2. By a quirk of nature, the intraocular pressure is still normal. Light perception and projection are good. An iris claw lens, although virtually unknown in some parts of the world, is an excellent exchange lens. It can be fixed with minimal trauma to the iris and is well tolerated.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Cohen JS, Osher RH, Weber P, Faulkner JD. Complications of extracapsular cataract surgery. The indications and risks of peripheral iridectomy. Ophthalmology. Jul 1984;91(7):826-30. [Medline].
• Del Priore LV, Robin AL, Pollack IP. Neodymium: YAG and argon laser iridotomy. Long-term follow-up in a prospective, randomized clinical trial. Ophthalmology. Sep 1988;95(9):1207-11. [Medline].
• Lynch MG, Brown RH, Michels RG, et al. Surgical vitrectomy for pseudophakic malignant glaucoma. Am J Ophthalmol. Aug 15 1986;102(2):149-53. [Medline].
• Naveh-Floman N, Rosner M, Blumenthal M. Pseudophakic pupillary block glaucoma with posterior-chamber intraocular lens. Glaucoma. 1985;7:262.
• Tomey KF, Senft SH, Antonios SR, et al. Aqueous misdirection and flat chamber after posterior chamber implants with and without trabeculectomy. Arch Ophthalmol. Jun 1987;105(6):770-3. [Medline].
• Tomey KF, Traverso CE, Shammas IV. Neodymium-YAG laser iridotomy in the treatment and prevention of angle closure glaucoma. A review of 373 eyes. Arch Ophthalmol. Apr 1987;105(4):476-81. [Medline].
• Vajpayee RB, Angra SK, Titiyal JS, et al. Pseudophakic pupillary-block glaucoma in children. Am J Ophthalmol. Jun 15 1991;111(6):715-8. [Medline].

Article Last Updated: Feb 2, 2007