Pupilloplasty And Iol Scleral Fixation 30 Years After Complicated Intracapsular Cataract Extraction

We present the difficult case of prior intracapsular cataract extraction 30 years ago (1993) in the right eye trough corneoscleral incision which resulted in a large iatrogenic ectopic pupil due to iris entrapment in the incision. Anterior OCT measured 5.6 mm ectopic pupil and revealed atrophied iris tissue fused superiorly to the cornea, with degeneration of the irido-corneal structures. During surgery iris tissue was freed using mechanical adherence lysis via spatula, vitreous cutter. Endodiathermy pupilloplasty centered the pupil and sutureless anchoring was performed for the IOL via extended scleral pockets in the haptic directions and haptic enclaving. The iris defect was treated using Siepser knot pupilloplasty.

Department of Ophthalmology, Clinical Hospital for Ophthalmological Emergencies Bucharest, Romania. “Carol Davila” University of Medicine and Pharmacy Bucharest

We present the difficult case of a patient with prior intracapsular cataract extraction 30 years ago (1993) in the right eye through corneoscleral incision with resultant iatrogenic ectopic pupil due to iris entrapment in the incision. The patient had decreased visual acuity, increased photosensitivity; BCVA 0.1 decimal. Clinical examination revealed corneal guttae, superior corectopia, vitreous strands at the pupillary edges, aphakia. Posterior pole examination was normal; IOP17mm Hg. Anterior OCT measured 5611µm ectopic pupil and revealed atrophied iris tissue superiorly, fused in contact with the cornea and degenerated with synechiae adherences. Intraoperatively scleral pockets were created 3mm from limbus, 180° apart. Anterior vitrectomy was performed, moving the vitreous cutter close to the pupillary edge, to eliminate vitreous traction. Iris mobilization was unsuccessful. Adherence lysis via spatula and vitreous cutter was done. With the iris now freed pupilloplasty using endodiatermy was performed to center the pupillary orifice. 21.00D three-piece IOL was injected and the first haptic was loaded into a 27G guide-needle, inserted exterior-to-interior from the scleral pocket-flap. The haptics were exteriorized similar to the Yamane technique and a Siepser knot pupilloplasty with 10-0 nylon suture treated the iris defect. Haptics were enclaved into the extended scleral pockets for sutureless scleral-fixation. Postoperative evolution was uneventful; UCVA 0.3 decimal.

Intracapsular cataract extraction is a historically proven technique preceding later phaco-emulsification extracapsular extraction technique. Among cited complications are iatrogenic induced iris defects, which were difficult to resolve with then-available anterior iris-fixated IOLs. Evolution of the surgical technique provide new solutions for older cases. In this case we combined sutureless scleral fixation of a three-piece IOL with mechanical, endodiathermy-assisted and Siepser knot pupilloplasty to resolve a 30-year-old long-standing pupillary defect and surgical aphakia. The outcome was successful. We thus recommend further interest into combined pupilloplasty with scleral fixation of IOLs, which can help even in older cases.