History
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:
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Pain in the affected eye
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Unilateral headache
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Blurred, steamy vision
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Photophobia
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Haloes around lights
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Intense redness
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Nausea and vomiting (sometimes)
Adults
In adults, deteriorating vision and increasing discomfort and pain are noticed and reported.
Children
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.
Physical
A complete eye examination should be performed. Visual acuity usually is reduced depending upon the amount of corneal edema induced by the high IOP.
Pupillary examination
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.
IOP
Normal in very early cases, but IOP rapidly rises as the condition advances. IOP in excess of 50 mm Hg is not unusual.
Gonioscopy
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.
Fundus examination
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.
Causes
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.
Inflammation
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:
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Blood
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Fibrin
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Vitreous
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Lens material
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Wound leak (may cause shallowing of the anterior chamber, allowing the IOL optic to move forward)
Proliferative
Proliferative causes may include the following:
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Elschnig pearls blocking the peripheral iridectomy
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Elschnig pearls closing the space between the iris and the IOL
Fibrotic changes
Formation of thick membrane in the pupillary area may occur.
Multifactorial
A combination of the above factors may cause this condition.
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Pseudophakic pupillary block precipitated by leakage of the incision line. This led to a chain reaction of forward movement of the posterior chamber lens, closure of the angle, intractable glaucoma, and iris-cornea touch over a wide area.
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Same patient as in the image above, 1 month after surgery. She underwent iridectomy at 3 places, separation of the iris from the cornea and the optic of the intraocular lens with viscoelastic material, and ab-interno filtration procedure at the 6-o'clock position, with erbium laser. The intraocular pressure is 13 mm Hg.
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Pupillary block in the presence of a posterior chamber lens. This stereo pair shows the closure of the peripheral iridectomy, dilated pupil, iris lens adhesions, and fibrotic membrane formation in the whole of the pupillary area. A large area of the iris shows iris bombe formation.
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This 5-year-old child, a case of congenital cataract, earlier had pupillary block and moderate iris bombe, which was relieved by 2 shots of Nd:YAG on the ballooned iris and the peripheral iridectomy opening.Two weeks later, he came back with a much worse pseudophakic pupillary block and multiloculated ballooning of the iris. The intraocular pressure was raised. Pigment and exudates were on the surface of the intraocular lens. The condition was relieved by reopening the peripheral iridectomy site, removing the posterior capsule in the pupillary area; performing iridectomy along the upper pupillary margin, a small central anterior vitrectomy and cleaning the intraocular lens with the help of a vitrector. The anterior chamber was deepened with a large air bubble. The recovery was uneventful.
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One month postoperatively of the patient above, the cornea was clear, the anterior chamber was deep, a few peripheral anterior synechiae were present, the pupillary area was clear, the pigment on the periphery of the intraocular lens had been reduced, the intraocular pressure was normal, and corrected visual acuity was 20/80. The patient remained free from a pupillary block thereafter.
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Pseudophakic pupillary block observed in a case of posterior chamber lens. The pupil is closed and deformed by the optic of the lens and the fibrous tissue, but the consequences of pupillary block are missing due to the presence of a patent peripheral iridectomy.
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The patient is 6 years old. Closure of peripheral iridectomy, lens decentration, partial pupil capture, and adhesions between the optic and the iris have produced pupillary block. One of the loops has started cheese-wiring the iris. Iris bombe is all around. Iris incision line adhesions are visible. The intraocular pressure is normal.
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With the help of a vitrector, the central part of the iris has been moved over and close to the optic. No attempt has been made to reposition the optic of the lens. The peripheral iridectomy is left as such. The iris bombe has settled nicely.
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Pediatric iris claw lens implantation, showing a pupillary block that has been precipitated by the closure of the peripheral iridectomy with Elschnig pearls. The pupil has been closed with the optic of the lens. A vertical fibrotic band courses vertically across the edge of the optic. The 360º iris bombe has encouraged adhesion formation between the iris and the perimeter of the lens.Treatment in these cases involves removing Elschnig pearls, opening and enlarging the existing iridectomy, making an additional iridectomy elsewhere, cutting the fibrous band, separating the iris from the optic, doing a small anterior vitrectomy, and enlarging the pupil with a vitrector toward the 12-o'clock position (so that the edge of the pupil goes beyond the edge of the optic).
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The stereo pair shows pseudophakic pupillary block in a brown eye. No peripheral iridectomy is visible. The pupil is dilated, and the iris is adherent to the optic of the lens. An amorphous, translucent membrane is present on the surface of the lens. The treatment involves a surgical iridectomy, clearing the optical axis of any obstacle, and performing a small anterior vitrectomy.
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A 60-year-old patient with a light-colored iris presents with pseudophakic pupillary block. Lens implant surgery was performed 6 months ago. The pupil is dilated moderately. There are adhesions with the optic of the posterior chamber lens. One loop of the lens is pushing itself into the anterior chamber. Iris bombe is seen in 360º. Most of the iris from the 6-o'clock position to the 11-o'clock position is in contact with the endothelium. A round continuous curvilinear capsulorrhexis is visible, in front of which the optic of the lens lies. The patient has been experiencing eye aches for 2 months. Intraocular pressure is 35 mm Hg. A filtration operation for glaucoma with 1 or 2 iridectomies suffices for control of glaucoma and for clearing the pupillary block. Further intervention depends on the progress of the case.
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A 56-year-old patient presents with a 4-loop-angle-supported lens. Two loops are visible, while the other loops are hidden under the iris tissue. From the 10-o'clock position to the 3-o'clock position, the edge of the optic is hidden under the overgrown iris tissue. A translucent membrane, 4-cornered in shape, is adherent to the anterior surface of the optic. A peripheral iridectomy is not visible. The pupil is blocked with pigment and scar tissue. The optic of the lens is acting like a perfect lid over the pupil. Iris bombe is all around, more so in the upper half. The endothelial cell count is 1700 cells/mm2. By a quirk of nature, the intraocular pressure is still normal. Light perception and projection are good. An iris claw lens, although virtually unknown in some parts of the world, is an excellent exchange lens. It can be fixed with minimal trauma to the iris and is well tolerated.
