Laboratory Studies

The following laboratory studies may be used:

Blood sugar
Clotting and bleeding time

B-scan

Routine B-scan helps to identify the presence of a fallen nucleus, retained cortical matter, blood, and exudates in the vitreous.

Usually, choroidal hemorrhages can be seen easily.

A high-quality B-scan may identify anterior movement of the posterior vitreous compatible with aqueous misdirection.

Optical coherence tomography (OCT)

It helps to document the relationship between the periphery of the iris and the angle of the anterior chamber. It works best if the cornea is clear.

Ultrasound biomicroscopy

It is helpful in visualization of the structures behind the opaque iris. The position of the intraocular lens and the fluid space available behind the iris and around the ciliary body allow the peripheral anterior synechiae (PAS) to be easily seen.

Treatment & Management

Media Gallery

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.

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Author

Mitchell V Gossman, MD Partner and Vice President, Eye Surgeons and Physicians, PA; Medical Director, Central Minnesota Surgical Center; Clinical Associate Professor, University of Minnesota Medical School

Mitchell V Gossman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Minnesota Medical Association, North American Neuro-Ophthalmology Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, The Scientific Research Honor Society, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Douglas R Lazzaro, MD, FAAO, FACS Chairman, Professor of Ophthalmology, The Richard C Troutman, MD, Distinguished Chair in Ophthalmology and Ophthalmic Microsurgery, Department of Ophthalmology, State University of New York Downstate Medical Center; Chief of Ophthalmology, Director of Cornea, Director of Surgical Training, Kings County Hospital Center

Douglas R Lazzaro, MD, FAAO, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, Association of University Professors of Ophthalmology, Brooklyn Ophthalmological Society, Cornea Society, New York Society for Clinical Ophthalmology, Ophthalmic Laser Surgical Society

Disclosure: Nothing to disclose.

Additional Contributors

Daljit Singh, MBBS, MS, DSc † Professor Emeritus, Department of Ophthalmology, Guru Nanak Dev University; Director, Daljit Singh Eye Hospital, India

Daljit Singh, MBBS, MS, DSc is a member of the following medical societies: All India Ophthalmological Society, American Society of Cataract and Refractive Surgery, Indian Medical Association, International Intra-Ocular Implant Club, Intraocular Implant and Refractive Society, India

Disclosure: Nothing to disclose.

Neil T Choplin, MD Adjunct Clinical Professor, Department of Surgery, Section of Ophthalmology, Uniformed Services University of Health Sciences

Neil T Choplin, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Association for Research in Vision and Ophthalmology, California Association of Ophthalmology, San Diego County Ophthalmological Society, Society of Military Ophthalmologists

Disclosure: Nothing to disclose.