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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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  Table of Contents 
CASE REPORT
Year : 2012  |  Volume : 19  |  Issue : 3  |  Page : 334-336  

Bilateral traumatic expulsive aniridia after phacoemulsification


1 Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
2 Department of Ophthalmology, Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA

Date of Web Publication3-Jul-2012

Correspondence Address:
Mark W Lunde
Department of Ophthalmology, Jesse Brown Veterans Affairs Medical Center, 820 S. Damen Ave., Chicago, IL 60612
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.97948

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   Abstract 

We report a case of bilateral traumatic expulsive aniridia after uneventful phacoemulsification through small clear corneal incisions. Phacoemulsification was performed 8 and 13 months prior to the trauma in the left and right eyes, respectively. In both eyes, the intraocular lens and capsular bag were undisturbed after trauma. After resolution of hyphema, transient elevated intraocular pressure, and anterior chamber inflammation, best corrected visual acuity returned to 20/25 in each eye 6 months later. Self-sealing clear corneal wounds likely serve as a decompression valve during blunt trauma, thus preventing devastating intraocular damage and globe rupture. The intraocular lens may absorb the external force, therefore preventing damage to the capsular bag and zonules as well as preventing prolapse of posterior structures. A review of previously reported cases of traumatic aniridia is also presented.

Keywords: Ocular Trauma, Phacoemulsification, Traumatic Aniridia


How to cite this article:
Oltra EZ, Chow CC, Lunde MW. Bilateral traumatic expulsive aniridia after phacoemulsification. Middle East Afr J Ophthalmol 2012;19:334-6

How to cite this URL:
Oltra EZ, Chow CC, Lunde MW. Bilateral traumatic expulsive aniridia after phacoemulsification. Middle East Afr J Ophthalmol [serial online] 2012 [cited 2019 Jun 18];19:334-6. Available from: http://www.meajo.org/text.asp?2012/19/3/334/97948


   Introduction Top


With advances in cataract surgery, small, self-sealing, clear corneal wounds are now the standard of practice. These wounds have been tested in cadaver eyes and proven to withstand high levels of external pressure. [1],[2] With blunt ocular trauma, these post-surgical eyes are especially prone to injury. We report a case of bilateral iris expulsion following two separate incidents of blunt trauma. Both lenses and capsular bags were left intact. Even with small sutureless corneal wounds, iris expulsion can still occur.


   Case Report Top


An 87-year-old African American female underwent uneventful phacoemulsification of her right eye followed by her left eye 3 weeks later. An acrylic one-piece intraocular lens (IOL) (SN60WF; Alcon Labs, Fort Worth, TX, USA) was placed through a 2.85-mm clear corneal incision inside the capsular bag in the right eye and a silicone three-piece IOL (LI61A0; Bausch and Lomb Inc., Rochester, NY, USA) was placed through a 3.2-mm clear corneal incision in the left eye. Postoperative best corrected visual acuity (BCVA) was 20/25 in both eyes. Eight months postoperatively, the patient fell and struck the left side of her head on concrete. She immediately noticed decreased vision and pain. Ophthalmic evaluation of the left eye was performed 1 day following the trauma, and the BCVA was 20/50 and intraocular pressure (IOP) was 34 mm Hg in the left eye. The patient had significant upper and lower eyelid edema and ecchymosis. Slit-lamp examination revealed 2+ microcystic edema and pigment and minimal loose iris tissue was present at the clear corneal incision. The incision was Seidel negative. The anterior chamber was deep and well formed with a 2.4-mm hyphema. There was no remaining loose iris tissue elsewhere. The posterior chamber IOL was intact inside the capsular bag. The posterior segment exam was unremarkable. The patient was started on topical IOP lowering medications, moxifloxacin four times daily and prednisolone acetate six times daily which were tapered over 1 month.

At the 1-month follow-up visit, the BCVA was 20/30 and IOP was 18 mm Hg in the left eye. The patient was taken to the operating room 2 months after the trauma for a revision of the phacoemulsification wound, with excision of the loose iris tissue within the wound.

The patient progressed well after revision surgery until she fell again 4 months later hitting her right periorbital area on concrete. The BCVA in the right eye on the day following trauma was 20/40 and the IOP was 19 mm Hg. On slit-lamp examination, she had a small amount of pigment at the corneal phacoemulsification wound, which was Seidel negative. The anterior chamber was well formed with a 2-mm hyphema. There was no visible remaining loose iris tissue elsewhere. The posterior segment exam was unremarkable. The patient was started on topical prednisolone acetate four times daily tapered over 1 month.

On the 6-month follow-up visit, the BCVA was 20/25 and the IOP in both eyes had remained normal. The capsular bag and IOLs remained intact in both eyes [Figure 1]. She denied glare and the need for colored contact lenses.
Figure 1: Total traumatic aniridia with the intraocular lens undisturbed in the capsular bag in the right (a) and left (b) eyes. Trauma occurred 8 and 13 months after uneventful phacoemulsification in the left and right eye, respectively

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   Discussion Top


Traumatic iris expulsion through a sutureless phacoemulsification 5 mm × 3.5 mm scleral tunnel wound was first described by Navon in 1997. [3] The authors proposed that the mechanism of injury involved aqueous outflow and iris plugging of the surgical wound, resulting in a pressure gradient across the tunnel sufficient to detach the iris and deliver it through the wound. [3]

In 2001, Ball described traumatic aniridia through a 4 mm x 2 mm clear corneal incision. [4] Since these previous reports, several cases have been described of iris expulsion through a clear corneal incision following blunt trauma. [Table 1] summarizes the case reports in the literature. [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13]
Table 1: Summary of reported cases in the literature of traumatic aniridia after phacoemulsification[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13]

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It has been proposed that new foldable IOLs absorb the impact of the external force to a greater degree than rigid polymethyl methacrylate (PMMA) IOLs, thus preventing disruption of the capsule and zonules. [7] It has also been postulated that the posterior structures are protected from prolapse by the presence of the posterior chamber IOL. [8] Both of these mechanisms may have contributed to the absence of trauma to the capsular bag, IOL, and posterior structures.

Though cases exist in the literature of traumatic aniridia following blunt trauma to pseudophakic eyes, our case is unique in that it is the first case of bilateral iris expulsion and also through the smallest reported wound size of 2.85 mm. It is also interesting that different IOL models were used in each eye and neither sustained any damage despite trauma. The main complaint in similar cases is usually glare and photosensitivity. Management options include observation, colored contact lenses, and prosthetic iris implants. [14]

 
   References Top

1.Ernest PH, Lavery KT, Kiessling LA. Relative strength of scleral corneal and clear corneal incisions constructed in cadaver eyes. J Cataract Refract Surg 1994;20:626-9.  Back to cited text no. 1
[PUBMED]    
2.Ernest PH, Fenzl R, Lavery KT, Sensoli A. Relative stability of clear corneal incisions in a cadaver eye model. J Cataract Refract Surg 1995;21:39-42.  Back to cited text no. 2
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3.Navon SE. Expulsive iridodialysis: An isolated injury after phacoemulsification. J Cataract Refract Surg 1997;23:805-7.  Back to cited text no. 3
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4.Ball JL, McLeod BK. Traumatic wound dehiscence following cataract surgery: A thing of the past. Eye (Lond) 2001;15:42-4.  Back to cited text no. 4
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5.Routsis P, Garston B. Late traumatic wound dehiscence after phacoemulsification. J Cataract Refract Surg 2000;26:1092-3.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Blomquist PH. Expulsion of an intraocular lens through a clear corneal wound. J Cataract Refract Surg 2003;29:592-4.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Muzaffar W, O'Duffy D. Traumatic aniridia in a pseudophakic eye. J Cataract Refract Surg 2006;32:361-2.  Back to cited text no. 7
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8.Lim JI, Nahl A, Johnston R, Jarus G. Traumatic total iridectomy due to iris extrusion through a self-sealing cataract incision. Arch Ophthalmol 1999;117:542-3.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Ball J, Caesar R, Choudhuri D. Mystery of the vanishing iris. J Cataract Refract Surg 2002;28:180-1.  Back to cited text no. 9
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10.Kahook MY, May MJ. Traumatic total iridectomy after clear corneal cataract extraction. J Cataract Refract Surg 2005;31:1659-60.  Back to cited text no. 10
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11.Prabu A, Nayak H, Palimar P. Traumatic expulsive aniridia after phacoemulsification. Indian J Ophthalmol 2007;55:232-3.  Back to cited text no. 11
    
12.Sheth HG, Laidlaw AH. Traumatic aniridia after small incision cataract extraction. Cont Lens Anterior Eye 2006;29:163-4.  Back to cited text no. 12
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13.Walker NJ, Foster A, Apel JJ. Traumatic expulsive iridodialysis after small-incision sutureless cataract surgery. J Cataract Refract Surg 2004;30:2223-4.  Back to cited text no. 13
    
14.Ozturk F, Osher RH, Osher JM. Secondary prosthetic iris implantation following traumatic total aniridia and pseudophakia. J Cataract Refract Surg 2006;32:1968-70.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  


    Figures

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