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Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999
Blunt ocular trauma occurring in the postoperative period after cataract extraction can result in severe visual loss with extrusion of iris, vitreous, and retinal tissue through the ruptured cataract wound. We report a case of isolated iris loss in a pseudophakic patient who had undergone sutureless cataract extraction and intraocular lens implantation. There are reports of phakic patients who developed isolated traumatic aniridia after corneal and scleral ruptures.1-4 To our knowledge, this is the first case of isolated traumatic total iridectomy in a pseudophakic patient.
An 82-year-old woman with age-related macular degeneration and geographic atrophy had undergone cataract extraction of the right eye and intraocular lens implantation. The scleral self-sealing cataract wound was posterior to the limbus and was 5.25 mm in length. She did well until 12 weeks later, when she fell and struck her right orbital region on a cabinet edge while on vacation. She noted an immediate loss of vision to the level of hand motions. Four days later, upon returning to Los Angeles, Calif, she came to us for an ophthalmologic examination.
Examination of the right eye showed light perception visual acuity with marked ecchymosis of the eyelids and orbital region. Slitlamp examination revealed the superior 5 clock hours positions of the bulbar conjunctiva to have a grayish discoloration. A layered hyphema occupied 75% of the anterior chamber. The remaining portion of the anterior chamber was filled with a dispersed hyphema. There was no view of the iris or posterior segment structures. Applanation pressures were 38 mm Hg in the right eye and 16 mm Hg in the left. Because of the possibility of an occult-ruptured globe, the patient underwent surgical exploration of the globe that same morning.
Surgical exploration disclosed a blue-gray iris lying in the subconjunctival space adjacent to a self-sealing superior scleral cataract wound. The iris, admixed with Tenon capsule and blood, was adherent to the underlying sclera. Three interrupted 10-0 nylon sutures were placed to close the V-shaped scleral cataract wound. The anterior chamber hyphema was then evacuated. No iris was found inside the eyeball. The posterior chamber intraocular lens was in good position in the lens capsular bag (Figure 1).
A slitlamp photograph of the patient's right eye shows the intraocular lens suspended in the capsular bag. There is no iris. The ciliary process tips are visible (arrow).
One month later, a pars plana vitrectomy was performed to evacuate a persistent vitreous hemorrhage. Visual acuity improved from hand motions preoperatively to 20/300 postoperatively. Intraocular pressure stabilized at 21 mm Hg. The visual acuity was limited to 20/300 by geographic atrophy due to age-related macular degeneration.
Isolated traumatic expulsion of the iris has been described in association with contusion injuries to the globe in phakic patients. To our knowledge, this is the first report of traumatic total iridectomy in a pseudophakic patient with retention of a posterior chamber intraocular lens implant.
Previous reports described patients in whom the iris was expulsed through a corneoscleral laceration1-3 or through a full-thickness glaucoma fistula.4 Romem and Singer1 described a man who was struck by a piece of wood and suffered a corneoscleral laceration extending from the limbus to the equator temporally. That patient was found to have isolated traumatic total iridectomy; the natural lens was intact. During a 2-year follow-up, the visual acuity recovered and was maintained at 20/20. The authors postulated that a glass splinter (attached to the wood) lacerated the cornea, engaged the prolapsing iris, and tore the iris from the iris root.
In their series of traumatic aniridia, Trobe and Keeney2 described a patient who suffered traumatic total iridectomy without traumatic aphakia. Their patient had been struck in his eye by a rock fragment while riding a motorcycle. An iris fragment was found in the corneoscleral wound; the natural lens was intact. Follow-up during the next 6 months showed maintained 20/25 visual acuity and normal intraocular pressure.
There have been reports of 2 other patients with traumatic total iridectomy after suffering small perforating perilimbal wounds.3 In 1 patient, the iris extruded through a full-thickness glaucoma fistula when the conjunctival bleb ruptured.4 It was postulated that an abrupt rise of intraocular pressure led to extrusion of the iris through the fistula.
In our patient, we postulate that the blunt trauma led to an abrupt elevation of the intraocular pressure. As a result of the force exerted on the globe and the elevated intraocular pressure, the previously closed self-sealing corneoscleral incision opened and the iris extruded through the incision. With the sudden expansion of the eyeball after the impact, the iris, stuck in the wound, was avulsed from the iris root. The posterior structures were held back by the intraocular lens implant. This occurrence of traumatic total iridectomy due to blunt trauma in the setting of a self-sealing cataract wound has not been previously reported. Fortunately, due to the intraocular lens implant's presence, there was a good outcome.
Reprints: Jennifer I. Lim, MD, Doheny Eye Institute, USC School of Medicine, 1450 San Pablo St, Suite 4703, Los Angeles, CA 90033 (e-mail: firstname.lastname@example.org).
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(4):542–543. doi:
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