Clinical and Experimental Vision and Eye Research

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Aphakic pupillary block: A case study and review of theliterature
  CLEVER
CASE REPORT
Aphakic pupillary block: A case study and review of the
literature
Elinor Megiddo Barnir, Amir Hadayer, Noa Geffen, Alon Zahavi
Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva; affiliated to Sackler Faculty of Medicine, Tel Aviv University,Tel Aviv, Israel
Address for correspondence: Alon Zahavi, Department of Ophthalmology,Rabin Medical Center - Beilinson Hospital,Petach Tikva 4941492, Israel.
Tel.: +972-3-9376101.
E-mail: alonzahavi@gmail.com
Received: 05-02-2018;
Accepted: 09-04-2018
doi: 10.15713/ins.clever.10
 
ABSTRACT
This study was aimed to describe a case study of a 75-year-old male patient with aphakicpupillary block. Angle-closure glaucoma is a sight-threatening condition. Pupillary blockis often a component of angle-closure glaucoma that has multiple possible etiologies.Prolapse of vitreous through the pupillary aperture as a cause of pupillary block isuncommon. Although laser iridotomy is the mainstay treatment in pupillary block, it isnot always an effective treatment strategy for this particular clinical scenario. A 75-yearoldmale presented to the emergency department with symptoms and signs compatiblewith aphakic acute angle closure secondary to vitreous prolapse through the pupillaryaperture, causing pupillary block. The patient was treated with topical intraocularpressure (IOP) lowering agents and systemic hyperosmotics resulting in a moderatedecrease in IOP. Treatment attempt to relieve the pupillary block component withNd: YAG laser iridotomy was ineffective. The second attempt at Nd: YAG laser aimedat the vitreous bubble protruding through the pupillary aperture was successful, withimmediate aqueous humor flow and deepening of the anterior chamber, IOP decrease,and resolution of symptoms. Anterior segment photographs and anterior segment opticalcoherence tomography (AS-OCT) scans obtained before and following the procedurewere useful in evaluating and documenting the clinical scenario and eventual vitreousblock resolution. We report an unusual case of vitreous pupillary block and treatmentstrategy using Nd: YAG laser vitreolysis. Anterior segment imaging, particularly ASOCT,is a useful auxiliary test for evaluation and documentation in such complex cases.
Keywords: Nd: YAG laser, pupillary block, vitreousprolapse
How to cite this article: Barnir EM, Hadayer A, Geffen N,Zahavi A. Aphakic pupillary block: A case study and review ofthe literature. Cli Exp Vis Eye Res J 2018;1(1): 48-50.
 
 

Introduction

Angle-closure glaucoma is a sight-threatening condition whichmay result in irreversible blindness. Pupillary block is oftena component of acute angle closure (AAC), which requiresemergency treatment. Essentially, a prevention of aqueousflow from the posterior to the anterior chamber through thepupillary aperture, pupillary block may be caused by posteriorsynechiae, a crystalline or artificial lens, silicone oil, or vitreoussubstance.[1-5] Prolapse of vitreous through the pupillaryaperture as a cause of pupillary block is uncommon and shouldbe managed carefully. Although laser iridotomy is consideredthe mainstay of treatment in pupillary block,[6,7] it is not alwaysan effective treatment strategy. Here, we present a case of anaphakic patient with vitreal pupillary block and its management.

 
Ophthalmologists should be aware of this condition andalternative treatment techniques.

Case Report

A 75-year-old male presented to the emergency department withacute redness and pain in his left eye. Medical history includeddiabetes and hypertension. He reported poor vision in his left eyesince childhood, estimated at hand motion, but was uncertainof the cause. Ophthalmologic evaluation of the right eye wasunremarkable. Left eye visual acuity was hand motion, withan intraocular pressure (IOP) of 60 mmHg. Anterior segmentexamination demonstrated conjunctival hyperemia, cornealmicrocystic edema, and shallow anterior chamber with peripheraliridocorneal touch, iris atrophy, and vitreous prolapsed throughthe pupillary aperture. Aphakia and a small hypoplastic optic discwith macular pallor and extensive chorioretinal atrophy werenoted. An appositionally closed angle was seen on gonioscopy.Due to corneal edema and resulting difficulty in detailed posteriorsegment examination, ultrasound imaging of the left eye wasperformed that revealed an elliptic hyperechogenic finding inthe inferior vitreous cavity adjacent to the retina, correspondingto a dropped crystalline lens [Figure 1]. Anterior segmentphotographs and anterior segment optical coherence tomography(Heidelberg Engineering GmbH, Heidelberg, Germany) (ASOCT)were used to document the vitreous prolapse leading topupillary block [Figures 2 and 3]. The patient was treated withtopical IOP lowering agents including Cosopt (Dorzolamide20 mg/ml, Timolol 5 mg/ml, Laboratoires Merck Sharp andDohme - Chibret, France), Alphagan (Brimonidine tartrate0.15%, Allergan, Inc. Irvine, CA, USA), Xalatan (Latanoprost0.005%, Pfizer, USA), and pilocarpine (2%). 70 mg of oral Sorbitol(Sorbitol, Pfizer) was administered. One hour later, IOP was stillhigh at 50 mmHg, and 1.5 mg/kg body weight of intravenousMannitol (Mannitol, Baxter, USA) was given. One hour later, IOPdecreased to 30 mmHg. Treatment attempt to relieve the pupillaryblock component with Nd: YAG (neodymium-doped yttriumaluminum garnet) laser iridotomy was ineffective although a patentiridotomy was achieved. A second attempt at Nd: YAG laser aimedat the vitreal bubble protruding through the pupillary aperture wassuccessful with immediate aqueous humor flow and deepeningof the anterior chamber [Figure 4]. IOP decreased to 12 mmHgwith resolution of the symptoms. The patient was discharged withdexamycin drops TID (Dexamethasone sodium phosphate 0.1%,Neomycin sulfate 0.5%, Vitamed Ltd., Israel). At 1-week followup,the patient was asymptomatic and reported improvement invision with best-corrected visual acuity of counting fingers in hisleft eye. IOP measured 14 mmHg with a clear cornea and a deepanterior chamber.

48 Clinical and Experimental Vision and Eye Research, January-June, Vol 1, 2018

Aphakic pupillary block: A Case study and literature review Barnir, et al.

Aphakic pupillary block: A case study and review of theliterature
Figure 1: Ultrasound imaging of the left eye demonstrating anelliptic hyperdense finding in the inferior vitreous cavity adjacent tothe retina, corresponding to a dropped crystalline lens

Aphakic pupillary block: A case study and review of theliterature
Figure 2: Anterior segment photograph showing peripheraliridocorneal touch, shallow anterior chamber, and a vitreous bubbleprolapsed through the pupillary aperture touching the cornea

 
Discussion

Glaucoma is the leading cause of irreversible blindnessworldwide.[8] A subtype of glaucoma AAC presents as anophthalmic emergency which should be managed carefully.IOP lowering medical therapy is recommended as the initialstep, followed by laser iridotomy to relieve the pupillary blockcomponent often present in AAC.[7] While it is known that aphakicpatients can present with AAC, as the vitreous substance hindersaqueous flow through the pupillary aperture, such reports arescarce in the literature. Waisoburd et al. reported a case of aphakicpupillary block which resolved after peripheral iridotomy.[9] Adifferent case of vitreous prolapse into the anterior chamberfollowing Nd: YAG capsulotomy, with ensuing pupillary blockglaucoma managed by laser iridotomy, was reported by Li et al.[5]

Aphakic pupillary block: A case study and review of theliterature
Figure 3: Anterior segment photographs and anterior segmentoptical coherence tomography showing peripheral iridocornealtouch, shallow anterior chamber, and a vitreous bubble prolapsedthrough the pupillary aperture

Aphakic pupillary block: A case study and review of theliterature
Figure 4: Anterior segment photograph post-laser vitreolysisshowing a deep anterior chamber and vitreous prolapsed throughthe pupillary aperture

Clinical and Experimental Vision and Eye Research, January-June, Vol 1, 2018 49

Barnir, et al. Aphakic pupillary block: A Case study and literature review

Unlike previously reported cases, however, peripheraliridotomy failed to relieve the pupillary block component in ourpatient, presumably as the iridotomy aperture was immediatelyblocked by the vitreous substance. Nd: YAG laser vitreolysis ofthe vitreous substance protruding through the pupillary aperturewas successful with immediate resolution of the angle-closureepisode and normalization of the IOP.

AS-OCT is a very practical imaging tool that is being usedwith increasing frequency for the diagnosis and documentationof anterior segment pathology.[10] It provides a detailed imagewith high spatial resolution compared with other anteriorsegment imaging modalities such as ultrasound biomicroscopy.Moreover, it does not require water immersion or direct probecontact with the eye, reducing patient discomfort and imagedistortion. In the case presented, anterior segment photographsand AS-OCT scans obtained before and following the procedurewere useful in evaluating and documenting the clinical scenarioand eventual vitreous block resolution.

Conclusion and Clinical Significance

We report an unusual case of vitreous pupillary block andtreatment strategy using Nd: YAG laser vitreolysis. Anteriorsegment imaging, particularly AS-OCT, is a useful auxiliarytest for evaluation and documentation in such complex cases.Ophthalmologists should be aware of the various treatmentoptions available and the potential benefit of advanced imagingfor diagnosis and documentation of such cases.

 
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