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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 902-903

The traumatic iris sunset


1 Department of Ophthalmology, Mahatma Gandhi Missions Institute of Medical Sciences, Navi Mumbai, Maharastra, India
2 Department of Ophthalmology, Melaka Manipal Medical College, Melaka, Malaysia

Date of Submission26-Jan-2022
Date of Acceptance12-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Priyanka Gandhi
711, PG Hostel, MGM Campus, Kamothe, Navi Mumbai, Maharastra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_257_22

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  Abstract 


Cataract extraction with intra-ocular lens (IOL) implantation is the most common sight-restoring surgery performed in the elderly. Blunt trauma is usually associated with severe ocular damage and grave consequences in post-operative eyes. Here, we report a case of a 70-year-old male, who suffered from blunt ocular trauma following one and a half month of phacoemulsification in the right eye. Phaco-tunnel wound was healthy, the iris was crumpled and settled at the bottom of anterior chamber, and the IOL was in the bag. There was no wound dehiscence. This is a rare presentation as the majority of reported cases had wound dehiscence and iris expulsion.

Keywords: Blunt trauma, iridodialysis, phaco-wound


How to cite this article:
Gandhi P, Hastak A, Ramakrishnan R, Shrivastava S. The traumatic iris sunset. Indian J Ophthalmol Case Rep 2022;2:902-3

How to cite this URL:
Gandhi P, Hastak A, Ramakrishnan R, Shrivastava S. The traumatic iris sunset. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Dec 3];2:902-3. Available from: https://www.ijoreports.in/text.asp?2022/2/4/902/358165



Cataract extraction with intrao-cular lens (IOL) implantation is the most common sight-restoring surgery performed in the elderly.[1] Phaco-emulsification is the most commonly preferred technique of cataract surgery because of small, self-sealing corneal ports, a faster healing process of wound, and a shorter rehabilitation time.[2] Blunt trauma is generally associated with severe ocular damage and grave concerns in post-operative eyes. Conversely, with the practice of phaco-emulsification and foldable lenses, existing literature suggests that after blunt trauma, these eyes suffer far less damage.[1]

Here, we report a case of a 70-year-old male, who suffered from blunt ocular trauma following one and a half month of phaco-emulsification and presented with traumatic iridodialysis and intact IOL in the bag.


  Case Report Top


A 70-year-old male patient presented to the ophthalmology out-patient department (OPD) with redness in the right eye following the history of injury by a stick 2 days back. The patient was operated for cataract surgery of the same eye 1 month and 20 days back. It was uneventful phaco-emulsification with implantation of an ACRYFOLD (hydrophilic) posterior chamber IOL. The patient had no history of systemic illness.

At presentation, the visual acuity in the right eye was 6/24, improving with pinhole to 6/18, and that of the left eye was 6/24p, improving with pinhole to 6/12p. On anterior segment examination, the right eye showed conjunctival congestion, mild corneal edema with healthy phaco-tunnel wounds, and iridodialysis from 8 to 5 o'clock. The iris was seen as a crumpled and settled tissue at the bottom of the anterior chamber. The anterior chamber depth was well maintained with hyphema and +3 cells. The capsulorrhexis margin was intact with the IOL in the bag [Figure 1]. The left eye showed immature cataract. The intra-ocular pressure (IOP) of both eyes was recorded as 14 mm Hg using a Goldmann applanation tonometer. On fundus examination of the right eye, media were hazy because of corneal edema and anterior chamber reaction; disc and vessels appeared grossly normal. B scan ultrasound of the right eye showed vitreous detachment. Left eye posterior segment examination was within normal limits.
Figure 1: At presentation: Iris and hyphema seen at the bottom and IOL positioned in the capsular bag in the right eye

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The patient was started on Tablet Prednisolone 40 mg once daily and Tablet Vitamin C 500 mg twice daily along with topical medications: E/D Prednisolone acetate 1% hourly, E/D Moxifloxacin 0.5% 4 times, E/D Homatropine 2% twice daily, and E/D Timolol 0.5% twice daily in the right eye.

On follow-up on day 7, the patient was symptomatically better. The visual acuity in the right eye was 6/24, improving to 6/18 with pinhole. Conjunctival congestion and corneal edema had reduced. Rest findings were the same as presentation. The IOP was 16 mm Hg in both eyes.


  Discussion Top


Blunt ocular trauma can cause severe structural damage such as complete iridodialysis, lens dislocation, vitreous hemorrhage, retinal detachment, and globe rupture.[3]

With the advancement of phaco-emulsification, available literature and knowledge show that there are mild effects of blunt ocular trauma with a more favorable course.

Navon reported the expulsion of the iris post blunt trauma through 5′ 3.5 mm corneoscleral phaco-emulsification wound.[4] In this case, complete iridodialysis was seen along with the iris tissue in the scleral tunnel, which had opened but not extended. The IOL and capsular bag were intact. Exploratory surgery was performed, and the prolapsed iris was excised. The visual acuity was 20/40 at 3 months.

Lim et al.[5] reported a case of retention of the iris tissue in a 5.2 mm self-sealing scleral wound in a post-operative eye after suffering from blunt ocular trauma.

Ball et al.[6] reported a case of total loss of the iris tissue through a 4′2 mm temporal corneal incision, with intact IOL in the bag and no wound extension. Conservative management was performed in this case.

The plausible mechanism of injury in these cases is transient wound distortion because of high-velocity aqueous flow across the wound. By the Bernoulli principle, a relative vacuum anterior to the iris is created. Prolapse of the iris occurs because the pressure gradient created between the anterior and posterior surfaces of the iris results into a localized iridodialysis and plugging of the wound.[7]

Sullivan et al.[8] reported a case of non-expulsive total loss of the iris following blunt trauma. There was disinsertion of the iris, which remained as a necrotic tissue in the anterior chamber and got phagocytosed by macrophages with IOP stabilization and the vision improving to the pre-trauma status without the need for long-term medications.

Various techniques have been suggested in the literature to repair an iridodialysis. Goldfeder (1932) reported the use of a small iris hook to incarcerate the fibers of a torn iris into a keratome-fashioned corneal incision. In 1933, Dr. Key reported the use of a Ziegler knife needle to pin the torn iris fibers into the corneal substance at the angle of iris.[9] McCannel's[10] iris suture technique became popular. Pandav et al.[11] suggested “Cobbler's technique” for traumatic iridodialysis repair. Because of the presence of inflammation and the risk of complications because of surgical intervention, we chose to monitor our patient with close observation and medical management.

Wound construction is an essential step in cataract surgery. In small incision cataract surgery, the scleral wound is made in the form of a scleral tunnel incision whose characteristics can be customized for each patient including length, depth, shape, width, and location. Wound integrity largely depends on the surgeon's expertise, which might also withstand traumatic conditions.

In our case, the patient presented 2 days after the trauma with a visual acuity of 6/18. Phaco-tunnel wound was healthy, the iris was crumpled and settled at the bottom of the anterior chamber, and the IOL was in the bag. There was no wound dehiscence. The IOP was normal, and the posterior segment was within normal limits.


  Conclusion Top


This is a rare presentation as the majority of reported cases had wound dehiscence and iris expulsion. Also, it highlights about the safety and good prognosis of phaco-emulsification surgeries withstanding high-intensity blunt trauma and maintaining the globe integrity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prabhu A, Nayak H, Palimar P. Traumatic expulsive aniridia after phacoemulsification. Indian J Ophthalmol 2007;55:232-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Thevi T, Reddy SC, Shantakumar C. Outcome of phacoemulsification and extracapsular cataract extraction: A study in a district hospital in Malaysia. Malays Fam Physician 2014;9:41-7.  Back to cited text no. 2
    
3.
Duke ES. Textbook of Ophthalmology. Vol VI: Injuries. St. Louis: MO, Mosby; 1954. p. 108-9.  Back to cited text no. 3
    
4.
Navon SE. Expulsive iridodialysis: An isolated injury after phacoemulsification. J Cataract Refract Surg 1997;23:805-7.  Back to cited text no. 4
    
5.
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. 5
    
6.
Ball J, Caesar R, Choudhuri D. Mystery of vanishing iris. J Cataract Refract Surg 2002;28:180-1.  Back to cited text no. 6
    
7.
Allan BD. Mechanism of iris prolapse: A quantitative analysis and implications for surgical techniques. J Cataract Refract Surg 1995;21:182-6.  Back to cited text no. 7
    
8.
Sullivan CA, Murray A, McDonnel P. The long-term results of nonexpulsive total iridodialysis: An isolated injury after phacoemulsification. Eye (Lond) 2004;18:534-6.  Back to cited text no. 8
    
9.
Key BW. Concerning iridodialysis as a clinical entity, its surgical treatment: Report of cases. Trans Am Ophthalmol Soc 1933;31:93-115.  Back to cited text no. 9
    
10.
McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976;7:98-103.  Back to cited text no. 10
    
11.
Pandav SS, Gupta PC, Singh RR, Das K, Kaushik S, Raj S, et al. Cobbler's technique for iridodialysis repair. Middle East Afr J Ophthalmol 2016;23:142-4.  Back to cited text no. 11
[PUBMED]  [Full text]  


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