Iris Prolapse Clinical Presentation

Updated: May 22, 2015
  • Author: Guruswami Giri, MD, FRCS; Chief Editor: Hampton Roy, Sr, MD  more...
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Presentation

History

The iris is a sensitive tissue in the eye. At the time of an iris prolapse, patients often experience pain. Patients with a perforated corneal ulcer frequently provide a history of severe pain that has since subsided.

The iris can prolapse after surgery (eg, cataract, corneal transplant), following trauma (eg, corneal laceration, scleral laceration), through a perforated corneal ulcer, or through a corneal melt associated with rheumatoid arthritis.

With improvements in microsurgical techniques, iris prolapse after surgery is uncommon.

Iris prolapse with a perforated corneal ulcer is rare.

In the author's experience, the most common cause of iris prolapse is following trauma; however, the exact incidence is not known.

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Physical

In peripheral iris prolapse, the iris appears as a knuckle of colored tissue, resulting in a partial peripheral synechia. When the prolapse is central, the entire pupillary margin may prolapse, resulting in a total anterior synechia. In patients with a perforated cornea, the prolapsed iris is exposed.

Depending on the duration of prolapse, the appearance of the iris may vary. In cases of recent prolapse, the iris appears viable. With time, the iris appears dry and nonviable. In patients who have undergone corneal transplant surgery or cataract surgery with a clear corneal incision, the appearance of the iris is the same as in a perforated cornea. When the iris prolapses through a scleral wound, it appears as a colored mass beneath the overlying conjunctiva. In this case, the iris remains viable for a long time.

The pupil appears peaked in the region of the iris prolapse. The anterior chamber is formed as the prolapsed iris seals the wound. Minimal or no wound leakage occurs. Wound leak is verified using the Seidel test. A drop of 2% fluorescein sodium is instilled in the conjunctival sac. The wound is examined under the slit lamp with cobalt blue light. The fluorescein appears greenish. Wound leak can be easily identified when the fluorescein is diluted by the aqueous humor. Gentle pressure on the eye may be needed to induce leakage.

Intraocular pressure is lower than normal, but hypotony is uncommon after iris prolapse.

In long-standing iris prolapse, chronic iridocyclitis, cystoid macular edema, or glaucoma may be seen. The prolapsed iris may act as a scaffold for infection, epithelial downgrowth, or fibrous ingrowth. Rarely, sympathetic ophthalmia may occur. Carefully examining the fellow eye for cells and flare is important.

Intraoperative floppy iris syndrome is graded as follows: [3]

  • Mild: Slightly noticeable floppy iris, minor or no miosis, and no tendency of iris prolapse
  • Moderate: Floppy iris, significant miosis, and small tendency for iris prolapse
  • Severe: Floppy iris, significant miosis, and strong tendency for iris prolapse
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Causes

Iris prolapse can occur following trauma, after surgery, through a perforated corneal ulcer, or through a corneal melt.

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