Pseudophakic Pupillary Block Treatment & Management

Updated: May 02, 2018
  • Author: Mitchell V Gossman, MD; Chief Editor: Douglas R Lazzaro, MD, FAAO, FACS  more...
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Treatment

Medical Care

Medical treatment for acute pupillary block is designed to lower IOP, to quiet the eye, and to clear corneal edema, thereby allowing visualization for peripheral iridectomy.

Analgesics may be administered as necessary. Antiemetics also may be necessary if nausea and vomiting are problematic.

To control IOP, immediate treatment includes topical beta-adrenoreceptor antagonists (beta-blockers), alpha2-agonists, and carbonic anhydrase inhibitors. Acetazolamide may be administered by mouth or, if the patient is nauseous and vomiting, by 500 mg IV push. Intravenous or parenteral hyperosmotics (1 g/kg of body weight) may effectively lower IOP immediately but transiently. Available agents include glycerin and isosorbide solution 45% weight/volume for oral use or mannitol (ie, 100 g in 500 cc IV drip, 12.5 g in 50 cc IV push) for intravenous administration.

Dilatation of the pupil may help relieve pupillary block in pseudophakia or break posterior synechiae.

Inflammation accompanying acute angle closure may be treated with topical steroids, adjusting the dosage as needed to quiet the eye.

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Surgical Care

The definitive procedure to break pupillary block is a peripheral iridectomy. This procedure usually can be accomplished using a laser (Nd:YAG, argon, or both), but, sometimes, in the case of severe inflammation, a surgical iridectomy may be necessary. Every attempt should be made to medically control IOP and to clear corneal edema before performing a laser iridectomy. Severe cases with membrane formation, nonclearing blood or inflammatory debris, or subluxed IOLs may require intraocular manipulation.

Peripheral iridectomy

A single peripheral iridectomy may be sufficient to break the block and to relieve the problem. A simple approach used by the author is as follows: A 1.5 mm tri-facet diamond knife is used to make a radial vertical incision in the periphery of the cornea. Iridectomy is done through it. The incision line is hydrated with saline. No suture is needed.

Multiple iridectomies may be necessary if multiple pockets of trapped aqueous are present behind the iris. This may be due to vitreous adherent to the iris or synechiae to the posterior capsule.

Laser iridectomies in inflamed eyes may be at risk for closure. If this is the case, they may be reopened or performed at another site. Surgical iridectomy may be more successful in such cases.

Fugo blade iridectomy: The Fugo blade is introduced through a 1 mm corneal incision. An opening of any desired size is made in the iris without pulling the tissue and without bleeding. Multiple iridectomies can be performed through the same incision, even on the opposite side of the limbus.

Fugo blade is very helpful in doing pupilloplasty and membranectomy, thus taking a large burden of management of difficult cases.

Freeing the pupil

Freeing the pupil involves the following:

  • Breaking iris-IOL synechiae

  • Removing inflammatory or fibrotic membranes

Removal of obstructive elements

Obstructive elements may include the following:

  • Blood

  • Lens matter

  • Elschnig pearls

  • Vitreous

  • Inflammatory exudates

Synechia and fibrotic membranes

The synechia and fibrotic membranes are best dealt with the Fugo blade. Any thickness of fibrous or fibrovascular scars can be incised or excised without bleeding and without any pull on the structures.

Vitrectomy

Vitrectomy may be necessary to remove vitreous from the anterior segment of the eye.

Manipulation of IOLs

Manipulation of IOLs involves the following:

  • Repositioning of IOLs

  • Explantation

  • Exchange

Filtration surgery

Filtration surgery is indicated if the anterior chamber angle fails to open following iridectomy, indicative of synechial closure, and IOP remains uncontrolled despite maximum tolerated medical therapy.

Transciliary filtration is an approach to manage glaucoma that departs from classic filtration surgery. [1, 2] This approach uses the tissue ablation and noncauterizing, hemostatic capabilities of the Fugo Blade (Plasma Blade). A nonbleeding micropore is created, which drains aqueous from behind the iris and into subconjunctival lymphatics. No peripheral iridectomy is needed.

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Activity

The relief of symptoms and the resulting visual function determines the return to normal activity. Generally, no limitation of activity is required following laser iridectomy. If filtration surgery is required, limitation of activity may be necessary for 7-10 days.

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