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Grand Ward Round : The Iris that was not there

Grand Ward Round : The Iris that was not there. Jocelyn Chua Medical Officer Trainee Tan Tock Seng Hospital The Eye Institute. His Story …. 33/C/gentleman Works in a cleaning company Known to have poor vision since childhood but had never consulted ophthalmologist

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Grand Ward Round : The Iris that was not there

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  1. Grand Ward Round : The Iris that was not there Jocelyn Chua Medical Officer Trainee Tan Tock Seng Hospital The Eye Institute

  2. His Story… • 33/C/gentleman • Works in a cleaning company • Known to have poor vision since childhood but had never consulted ophthalmologist • No other significant medical or surgical history • Recent complaint of gradual decrease in right eye vision with intolerable glare

  3. Examination finds … R : CF 2ft 6/120 Visual Acuity (Unaided) L : CF 3ft 6/120 Anterior segment Left eye Right eye IOP 20 Nystagmus Total aniridia No keratopathy / small corneal Diameter 10.5mm Shallow AC Cataract NS 1+ IOP 21 Nystagmus Iris remnant seen No keratopathy / small corneal diameter 10.5mm Shallow AC Cataract NS 2+

  4. Anterior Segment Photos Left Eye Right Eye

  5. Examination finds … Posterior segment Left eye Right eye Healthy disc / CDR 0.5 Loss of foveal reflex Retina normal Healthy disc / CDR 0.5 Loss of foveal reflex Retina normal

  6. His Family’s Story … 70 64      34 33

  7. Clinical Assessment … • Hereditary Aniridia • Bilateral cataracts R>L • Bilateral foveal hypoplasia with nystagmus • Borderline IOP with healthy optic discs Keen for surgery of right eye

  8. Management Options … • Observation with use of sunglasses • Full size iris implant • Small incision Morcher iris ring with foldable IOL • Ophtec IPS system Underwent Right phacoemulsification with implantation of Intraocular lens and Morcher 50C aniridia rings under GA on 14 June 2005 by Dr Chris Khng. Patient understood that visual acuity may not be significantly improved but glare will be reduced postop.

  9. video

  10. Postop anterior segment photo

  11. Postoperative Outcome … • VA Right eye : 6/120 POD1 6/45 POM1 • IOP normal • Subjective satisfactory reduction of glare

  12. Journal Review Cataract Surgery Combined with Implantation of an Artificial Iris J Cataract Refract Surg; Nov 1999 Vol 25, 1540-7 Robert H Osher, MD, Scott Burk MD PhD

  13. Purpose • Described 6 patients with cataract / aphakia and absent / nonfunctioning irides • Etiologies of absent / nonfunctioning irides include congenital aniridia, traumatic iris loss and chronic mydriasis secondary to herpetic uveitis

  14. Cases of congenital aniridia Case 1 • 25/F with congenital cataract + aniridia • VA (RE) hand movements / (LE) 20/400 • Underwent Right small incision phacoemulsification with insertion of Morcher type 50C into capsular bag • Anterior capsule tear with extension into posterior capsule during Morcher ring insertion • Postop VA (RE) 20/30 without glare symptoms

  15. Cases of congenital aniridia Case 2 • 49/F with Left congenital aniridia, cataract, foveal hypoplasia and glaucoma • Had intolerable glare with VA (LE) 20/250 • During CCC/phacoemulsification: abnormally fragile anterior capsule resulted in several peripheral tears • Single piece lens-iris diaphragm Morcher type 67F was implanted in ciliary sulcus • Postop VA (LE) 20/100without glare symptoms

  16. Cases of congenital aniridia Case 3 • 61/M with congenital aniridia, foveal hypoplasia, nystagmus and glaucoma • Had previous bilateral ECCE done but could not tolerate aphakic CL • VA (RE) 20/160 / VA (LE) 20/125 • Underwent Right implantation of single piece lens-iris diaphragm Morcher type 67F in ciliary sulcus • Postop VA (RE) remained at 20/160 but glare reduced

  17. Cases of traumatic aniridia Case 1 • 28/F with old Right penetrating eye injury with complete loss of nasal iris and traumatic cataract • VA (RE) 20/200 • Underwent Rightphacoemulsification followed by IOL implantation and placement of sector iris device type 96G in capsular bag till it occupied location of nasal iris defect • Postop VA (RE) 20/20 POW1 without glare

  18. Cases of traumatic aniridia Case 2 • 56/M with Right penetrating injury with total iris avulsion, ruptured anterior lens capsule with phacoanaphylactic glaucoma, 2 clock hour inferior zonulysis and vitreous hemorrhage • VA (RE) light perception • Phacoemulsification: • Small CCC created away from anterior capsule laceration • Noted also equatorial capsule rupture • Implantation of 2 Morcher type 50C iris rings in capsular bag through remote CCC site followed by placement of IOL over rings within torn capsule • Good centration of IOL and iris rings but VA compromised by persistent inflammation, cystoid macular edema, glaucoma and inferior retinal detachment

  19. Cases of traumatic aniridia Case 2

  20. Case of secondary chronic mydriasis Case 1 • 68/F with Right recurrent HSV granulomatous anterior uveitis resulting in severe iris damage with fixed dilated pupil • VA (RE) 20/200 • Underwent phacoemulsification and IOL implantation • Implantation of 2 Morcher Type 50C iris rings • Postop VA 20/20

  21. Learning points … Need for artificial iris rings established Endocapsular fixation possible Yes No 50C 67F But need a larger wound 96G

  22. Learning points … • Advantages of type 50C Morcher iris rings: • allows for small incision surgery thus sutureless • Separate optical system with foldable IOL • Good fundal view with postop pupil size 6mm • Disadvantage of type 50C Morcher iris rings: • Brittle and easily fractured • Insertion technique yet to be standardized (anterior/posterior/straddling IOL) • Crowded capsular bag with 3 devices in situ

  23. Learning points … • Other uses of artificial iris diaphragm: • Preventing silicone-endothelial contact after VR surgery

  24. Thank you

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