Iris Prolapse Treatment & Management

Iris prolapse is a serious condition that requires prompt medical management. As soon as the diagnosis is made, an eye shield should be applied to prevent further damage. Medical treatment is only indicated when the prolapse is small, is covered by the conjunctiva, and is without any other complications. In these cases, the eye may be observed.

Antibiotic eye drops and cycloplegics may be used during the acute stage. Intravenous antibiotics should be considered because infection from an iris prolapse can spread to the intraocular contents. Tetanus toxoid may be considered depending on the immunization status and the wound type.

In a prospective randomized study of 81 patients undergoing cataract surgery taking oral alpha-adrenergic agents, subtenon injection of 2% lidocaine significantly reduced the incidence of intraoperative floppy iris syndrome compared to 1% intracameral lidocaine. ^[5]

Prompt surgical management is necessary when conjunctival coverage is not present or in the presence of complications. The primary goal of surgery is to restore the anatomical integrity of the eye. Visual restoration is only a secondary goal. ^[6]

General anesthesia should be used during surgery. Retrobulbar anesthesia and peribulbar anesthesia are not recommended because they increase both intraorbital pressure and loss of additional intraocular tissue; however, they may be used if general anesthesia is contraindicated.

In cases of peripheral iris incarceration and a well-formed anterior chamber, acetylcholine (Miochol) may be administered. Acetylcholine is instilled through a paracentesis incision into the anterior chamber with gentle stroking of the iris. Acetylcholine constricts the pupil and may release the iris incarceration. Similarly, if the iris incarceration is central, intraocular epinephrine may be administered. Epinephrine dilates the pupil and helps to release the iris incarceration. ^[7]

If unsuccessful through a paracentesis incision, a viscoelastic agent is injected into the anterior chamber in the region of the iris prolapse. This mechanical force may be enough to release the prolapse and to reposition the iris. If the prolapse occurred within the previous 24-36 hours and if the iris is viable, the iris is reposited. If the iris does not appear viable, then it is excised. The iris should be excised if signs of epithelialization are present. To excise, the prolapsed iris is cut flush with the corneal surface. The iris defect may be closed using a 10-0 polypropylene suture on a vascular needle.

If the viscoelastic method is unsuccessful, then a cyclodialysis spatula with the longer end is introduced through the paracentesis incision. The spatula is swept from the center to the periphery of the prolapse to avoid unnecessary tension on the iris root. The corneal wound may be sutured depending on its length and integrity.

If the iris prolapse occurs after surgery, the same principle is used. The wound must be revised, or additional sutures should be applied to make the wound watertight.

When the iris prolapse occurs after a corneal perforation, the iris can be reposited. Cyanoacrylate glue and a bandage contact lens may be used to seal the perforation. If unsuccessful or if the perforation is large, an emergency corneal transplant is necessary.

Intraoperative floppy iris syndrome may be managed via modification of cataract surgical technique, use of preoperative atropine drops for pupillary dilation, intracameral epinephrine, ophthalmic viscoelastic devices, iris retractors, and pupil expander rings. ^{[4, 8]}

In patients with a corneal melt due to medical causes (eg, rheumatoid arthritis), appropriate consultations must be obtained.

The patient should not engage in contact sports because even a minor trauma can cause significant damage in an already compromised eye. The patient should be instructed to wear polycarbonate eyeglasses while working with mechanical devices and tools.