CHRONICALLY DILATED PUPIL WITH IRIS ATROPHY – HOW TO ADDRESS LONG-STANDING ADIE SYNDROME WITH ARTIFICIAL IRIS IMPLANT?

Iris defects may result in significant problems concerning visual function, including disabling photophobia, impaired contrast sensitivity and decreased visual acuity. Although artificial iris implants offer several tools to overcome these problems, the learning curve for implant placement is steep and implant choice is challenging.

The aim of this study is to report a clinical case where iris reconstruction using an endocapsular prosthetic device allowed good functional outcomes and to discuss other available iris implants to address iris defects.

We describe a case of a 77-year-old male patient presenting with marked symptoms of photophobia in the left eye (LE), with past history of long-standing bilateral Adie syndrome and fixed dilated pupils.

During examination, Best Corrected Visual Acuity (BCVA) in LE was 5/10. Biomicroscopic observation revealed LE nuclear cataract and severe diffuse iris atrophy, and pilocarpine 0.125% application did not trigger miosis. LE fundus observation was unremarkable. LE cataract surgery combined with artificial iris implant was proposed.

The patient underwent LE phacoemulsification followed by insertion of two overlying aniridia ring implants (Morcher 50F) in the capsular bag. At 6-months follow-up, the patient reported significant improvement of photophobia, LE BCVA of 10/10 and presented well centered endocapsular intraocular lens and aniridia ring implants.

Other prosthetic iris devices to be considered include rigid diaphragm with or without aniridic intraocular lens devices (Morcher GMBH 67 and Ophtec BV 311), which require a large incision (10.5 mm) and are suture-fixed in the ciliary sulcus. Moreover, there are flexible customized small-incision iris prostheses (HumanOptics CustomFlex®) which feature a subtle undulating contour in anterior iris surface to minimize light reflection, allow natural aesthetic appearance and require accurate centration of the artificial pupil.

Artificial iris implantation requires accurate surgical planning and appropriate patient selection to achieve better outcomes. Device selection is mainly influenced by iris defect configuration, ocular pathology and functional requirements. Despite the steep learning curve, iris rehabilitation may be accomplished with significant functional and quality of life improvements.