Pupillary Block, Aphakic Treatment & Management

  • Author: Deborah R Eezzuduemhoi, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: May 21, 2010
 

Medical Care

The management of pupillary block involves early recognition, relief of the pupillary block, medical treatment, and surgical treatment.

  • Medical treatment consists of intensive cycloplegia, mydriasis, and aqueous suppressants.
  • If the eye is inflamed, if the cornea is hazy, or if a peripheral iridotomy cannot be performed immediately, then the following agents are recommended:
    • Mydriatic agents (eg, cyclopentolate 2% and phenylephrine 2.5% q15min for 4 doses)
    • Carbonic anhydrase inhibitors (eg, acetazolamide, two 250-mg tab PO or 500 mg IV)
    • Topical beta-blockers (eg, timolol 0.5%), 1 dose
    • Topical alpha-agonists (eg, brimonidine 0.15% or apraclonidine 1%), 1 dose
  • In very early cases, relieving the block may be possible by the vigorous use of strong mydriatics alone or with hyperosmotic agents (glycerol 3 mL/kg PO, mannitol 1-2 g/kg IV). Posterior synechiae may be broken and herniation of a mushroomlike plug of vitreous may be relieved.
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Surgical Care

Surgical care consists of peripheral iridotomy, peripheral iridectomy, or incision of the hyaloid membrane. The length of time that the angle had remained closed is crucial in deciding the appropriate treatment.

  • Less than 2 weeks
    • Usually, a peripheral iridotomy or incision of the hyaloid membrane is adequate to relieve the block. Sometimes multiple iridotomies are needed because of loculation by vitreous to the posterior surface of the iris, resulting in multiple pockets of trapped aqueous.
    • Argon laser iridotomy can promptly relieve pure pupillary block by vitreous or other causes.
    • Photomydriasis (pupilloplasty) using argon laser is another modality of treatment. Radial rows of contraction burns can be applied for 360 degrees to create symmetric pupillary dilation or just in one quadrant to create focal dilation. This mode of treatment is used when creating an iridotomy is impeded by corneal edema. Laser peripheral iridoplasty using low energy contraction burns may also be used to deepen the anterior chamber angle. This may be combined with a pupilloplasty.
    • The Nd:YAG laser can be used to perform peripheral iridotomy, especially in an inflamed eye.
    • A thick brown iris may require treatment with both argon laser and Nd:YAG laser. If laser treatment is not successful, one may proceed as in the treatment of pupillary block greater than 2 weeks' duration.
    • Nd:YAG laser posterior capsulotomy is an alternative to laser iridotomy in selected cases of pupillary block following extracapsular cataract extraction without an intraocular lens.
    • A smaller than optical capsulotomy is recommended to lyse the adhesions. This may not be the treatment of choice because of the possibility of subsequent pupillary block by the vitreous.
    • Iris sphincterectomies may be performed with the Nd:YAG laser.
  • Greater than 2 weeks
    • Laser treatment is often not successful. Surgical iridectomy is the classic treatment of pupillary block in aphakic eyes.
    • Pars plana vitrectomy is another modality that may be performed.
    • If the angle has closed, a trabeculectomy with antimetabolites or a tube shunt procedure might be required.
    • Aphakic eyes with silicone oil or expansile gas placement require a large inferior iridotomy in the 6-o'clock position to decrease the risk of aphakic pupillary block.
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Consultations

A glaucoma specialist should be consulted.

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Contributor Information and Disclosures
Author

Deborah R Eezzuduemhoi, MD  Assistant Professor, Department of Ophthalmology and Visual Sciences, Texas Tech University, Health Sciences Center School of Medicine

Deborah R Eezzuduemhoi, MD is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, and Women in Ophthalmology, Inc

Disclosure: Nothing to disclose.

Coauthor(s)

Deborah Wilson, MD  Director of Glaucoma Service, Assistant Professor, Department of Ophthalmology, Georgetown University Medical Center

Deborah Wilson, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Neil T Choplin, MD  Adjunct Clinical Professor, Department of Surgery, Section of Ophthalmology, Uniformed Services University of Health Sciences

Neil T Choplin, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Association for Research in Vision and Ophthalmology, and California Medical Association

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

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  4. Beekhuis WH, Ando F, Zivojnovic R, et al. Basal iridectomy at 6 o'clock in the aphakic eye treated with silicone oil: prevention of keratopathy and secondary glaucoma. Br J Ophthalmol. Mar 1987;71(3):197-200. [Medline].

  5. Chandler PA. Glaucoma from pupillary block in aphakia. Arch Ophthalmol. 1962;7:44-47.

  6. Chandler PA, Simmons RJ. Gonioscopy during surgery for aphakic eyes with pupillary block. Am J Ophthalmol. Oct 1972;74(4):571-80. [Medline].

  7. Cotlier E. Aphakic flat anterior chamber. IV. Treatment of pupillary block by iridectomy. Arch Ophthalmol. Jul 1972;88(1):22-6. [Medline].

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  9. Koc F, Kargi S, Biglan AW, et al. The aetiology in paediatric aphakic glaucoma. Eye. Dec 2006;20(12):1360-5. [Medline].

  10. Mandal AK, Bagga H, Nutheti R. Trabeculectomy with or without mitomycin-C for paediatric glaucoma in aphakia and pseudophakia following congenital cataract surgery. Eye. Jan 2003;17(1):53-62. [Medline].

  11. Tomey KF, Traverso CE. Neodymium-YAG laser posterior capsulotomy for the treatment of aphakic and pseudophakic pupillary block. Am J Ophthalmol. Nov 15 1987;104(5):502-7. [Medline].

  12. Tomey KF, Traverso CE. The glaucomas in aphakia and pseudophakia. Surv Ophthalmol. Sep-Oct 1991;36(2):79-112. [Medline].

  13. Zborowski-Gutman L, Treister G, Naveh N, et al. Acute glaucoma following vitrectomy and silicone oil injection. Br J Ophthalmol. Dec 1987;71(12):903-6. [Medline].

 
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