Further Outpatient Care
Regular, prolonged follow-up care is needed to observe and preserve the normal anatomy of the anterior segment, the clarity of the refractive media, and the maintenance of normal IOP. Monitoring of visual fields and visual acuity also is important.
Pediatric patients need special care during the postoperative period. They may need sedation or even general anesthesia for a proper and thorough examination.
Examine for uveitis by performing a careful slit lamp examination at every visit. In particular, examine for the presence of aqueous flare and cells and deposits on both the corneal endothelium and the optics of the IOL. The position of the IOL is monitored for centration of the optic, deposition of pigment or foreign body giant cells, and any adhesions that may be developing with the iris. Lifelong, regular follow-up care is important. Explain at every visit the current status of the eye. Strongly advise the patient to come for regular check-ups after 1, 2, or 3 months or longer (as the situation demands).
Inpatient & Outpatient Medications
Local and systemic medication depends on both the condition and the needs of a particular patient.
Most of the operated cases generally need mydriatics, anti-inflammatory medications (steroidal and nonsteroidal), and antiglaucoma medicines.
The frequency of local instillation, the dose of oral medication, and the length of medication are determined by the needs of the individual patient.
Transfer
An experienced surgeon and adequate facilities must be available to manage these patients. If not available, transfer of the patient is warranted.
Complications
Patients with glaucoma who are untreated or poorly treated experience loss of visual acuity and visual fields, which may result in total visual loss.
Corneal decompensation may result from endothelial damage caused by the sudden rise in IOP or prolonged uncontrolled IOP. It also may result from contact with an anteriorly displaced IOL.
Uveitis may result from iris and/or ciliary irritation from the IOL or vitreous, as well as breakdown of the blood-aqueous barrier due to acute glaucoma. Surgery may lead to prolonged inflammation.
Chronic inflammation and/or vitreous in contact with the iris may lead to the development of cystoid macular edema with reduced visual acuity, even after the IOP problem has been corrected.
Prognosis
The earlier the condition is detected and adequately treated, the greater the chance of a full recovery. Once it is found that the pupillary block is not amenable to conservative treatment and an early surgical correction is instituted, the chances of recovery are excellent.
Patient Education
All patients undergoing intraocular surgery should be advised to contact the surgeon immediately if they experience pain or sudden decreases in vision in the postoperative period. These signs could indicate the development of pupillary block and acute glaucoma.
Patients should be aware of the need for regular follow-up visits to detect such problems before they result in serious vision-threatening conditions.
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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.
