Aphakic Pupillary Block Treatment & Management

Updated: Feb 18, 2019
  • Author: Mitchell V Gossman, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

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. [6] 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.

More 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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Complications

See the list below:

  • Iridectomy

    • Hyphema

    • Corneoscleral wound infection

  • Laser iridotomy - Hyphema

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Further Inpatient Care

It is necessary to check the IOP 1 hour after the operation.

The patient usually is discharged home after iridotomy or iridectomy with instruction to return to the eye clinic within 24 hours.

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