Pseudophakic Pupillary Block Clinical Presentation
- Author: Daljit Singh, MBBS, MS, DSc; Chief Editor: Hampton Roy, Sr, MD more...
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
Blurred, steamy vision
Haloes around lights
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.
A complete eye examination should be performed. Visual acuity usually is reduced depending upon the amount of corneal edema induced by the high IOP.
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.
Normal in very early cases, but IOP rapidly rises as the condition advances. IOP in excess of 50 mm Hg is not unusual.
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.
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.
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.
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
Physical blockage of the pupil may occur from many materials, including the following:
Wound leak (may cause shallowing of the anterior chamber, allowing the IOL optic to move forward)
Proliferative causes may include the following:
Elschnig pearls blocking the peripheral iridectomy
Elschnig pearls closing the space between the iris and the IOL
Formation of thick membrane in the pupillary area may occur.
A combination of the above factors may cause this condition.
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