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.
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.
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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.
-
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).
-
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.
-
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.
-
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.
