Pseudophakic Pupillary Block

Primary authors	KEOGT Team

Video Lecture: https://youtu.be/c3NaGH9AY9o

Causes and Clinical Findings

Figure 1: Iris-Optic Capture in an eye with a one piece IOL placed in the sulcus and subsequently dilated for retinal exam. The optic was captured by the iris and required surgical intervention to place the IOL in the capsular bag. See lecture link for further details. https://youtu.be/c3NaGH9AY9o

Causes

Iris capture (Figure 1)

Posterior synechiae

Iris to lens and/or anterior capsule

Closure of PI with lens/capsule block

Leaking wound with shallowing of AC

Soemmering ring pushing IOL forward

Upside down placement of IOL

Normally bowed posteriorly

Poor capsular support (zonules/rhexis)

Allows subluxation of lens

Any lens type: ACIOL, PCIOL (sulcus or capsule), piggyback

Clinical Findings

Irregular, poorly reactive pupil

Elevated IOP

May be normal early, rapidly rises >50

Corneal edema

Shallow AC peripherally

AC flare/cell

Posterior synechiae

Occluded PI

Iris Bombe

Iris atrophy/TIDs

Subluxed/displaced IOL

Iris capture

Risk Factors

Nanophthalmos (small crowded AC)

Weak zonules/poor capsular support

Sulcus IOL

Secondary piggyback lens

Undersized ACIOL

Large capsulorhexis

Upside down placement of IOL (anterior vault)

Phakic IOL

Prevention

This is a rare event

Capsulorhexis smaller than optic

Proper positioning of IOL (posterior vault)

Avoid placing single piece IOLs in the sulcus

Avoid piggyback lenses in small eyes

Proper size and position of LPI

Secure closure of wounds

Treatment

Initial Intervention

IOP reduction

Topical: PGA, BB, CAI, AA (avoid miotics)

Oral: Diamox

Definitive therapy – depends on mechanism

LPI for cases with iris bombe and posterior synechaie

Surgical manipulation with breaking of Iris-IOL or Iris-Capsule synechiae

Non-surgical or Surgical repositioning of IOL

Explantation or exchange of IOL

Filtering surgery-rarely needed in chronic cases where diagnosis was missed or delayed