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Background: To evaluate the frequency and anterior segment optical coherence tomography parameters of patients with scleral fixated intraocular lenses (IOL) and reverse pupillary block (RPB)., Methods: Retrospective analysis at a tertiary care centre (Department for Ophthalmology and Optometry, Medical University of Vienna, Austria). We researched our records for patients who underwent scleral fixated IOL implantation from January 2018 till February 2023. Patients were included only if there was at least one adequate post-operative scan of anterior segment optical coherence tomography (AS-OCT) available. Initially, AS-OCT scans were assessed for IOL tilt and decentration employing a 3D scan and then later for anterior chamber angle (ACA), aqueous anterior chamber depth (AQD), pupil diameter and iris-IOL distance using the 2D scan at a 0° angle. Both an iris-IOL distance of 0 or less and an ACA of more than 70° were required to define an RPB., Results: A total of 110 patients met the inclusion criteria, 41 were treated using the Carlevale, 33 the four flanged, 24 the Yamane and 12 the Scharioth technique, respectively. RPB was found in 32 patients (29%). Twenty patients with RPB were treated using YAG peripheral iridotomy, mean ACA decreased from 91.91° ± 13.77 to 61.02° ± 8.52, (p < 0.001), mean AQD decreased from 4.67 mm ± 0.47 to 4.31 ± 0.36 mm (p < 0.001) and mean iris-IOL distance increased from -0.09 ± 0.04 to 0.33 ± 0.30 (p < 0.001)., Conclusions: RPB is found in a third of eyes who have undergone scleral fixated IOL implantation without iridectomy. YAG peripheral iridotomy is a potent option to treat RPB, and subsequently reduce the risk of iris chafing and secondary inflammation or glaucoma., (© 2024 The Authors. Clinical & Experimental Ophthalmology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Ophthalmologists.)

Purpose: To characterize the morphology of persistent pupillary membranes (PPMs) in pediatric patients and explore the corresponding surgical approaches., Setting: Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China., Design: Prospective observational study., Methods: Consecutive pediatric patients with PPMs who underwent surgery from April 2020 to July 2022 were included. PPM morphology was assessed and categorized according to its anatomic relationship with crystalline lens and distribution of iris strands. The surgical approaches for different morphologies of PPMs were described in detail. The visual outcome and operation-related complications were recorded., Results: 31 eyes from 19 patients were included with the mean age of 7.2 years. 3 morphological variants of PPMs were observed: type I (51.6%, 16/31), a spider-like appearance and no adhesion to the anterior lens capsule (ALC); type II (38.7%, 12/31), a loose central adherence to the ALC and partially thick iris strands attached to the iris collarette; type III (9.7%, 3/31), a tight central adherence to the ALC and only silk-like iris strands. Surgeries were performed with a natural pupil size in type I, while dilated pupil in the other types. The adhesions between PPM and the ALC were separated by viscoelastic injection in type II and by discission needles in type III. The corrected distance visual acuity was significantly improved from 0.34 ± 0.18 logMAR preoperatively to 0.17 ± 0.09 logMAR postoperatively ( P < .001). No operation-related complications were observed during 9.5-month follow-up., Conclusions: PPMs were categorized into 3 types according to their different morphologies, which helped to determine the best surgical strategy., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS.)

Objective: The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression., Methods: A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS)., Results: Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months., Conclusions: With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

Purpose: The aim of this study was to describe a surgical method that can be easily and safely performed during Descemet membrane endothelial keratoplasty in patients who had previously undergone pars plana vitrectomy with transscleral fixation of the intraocular lens., Methods: This report reviewed 2 Descemet membrane endothelial keratoplasty procedures performed in patients with vitrectomized unicameral eyes. The proposed technique is characterized by the temporary suture of the pupillary aperture to block the forward flow of vitreous humor and prevent the abrupt loss of air tamponade due to backward movement of the air bubble into the vitreous cavity. At the same time, another air bubble is injected behind the scleral-fixated intraocular lens to induce forward movement of the iris-intraocular lens diaphragm through buoyancy. Thus, the depth of the anterior chamber is reduced, allowing easier unscrolling of the Descemet membrane endothelial keratoplasty lenticule., Results: Pupil closure and buoyancy of the air bubble allow the anterior chamber to be separated from the inflow of vitreous cavity fluid and maintained adequately shallow. During the keratoplasty, the graft is then easily unscrolled without the support of the capsular diaphragm. Postoperatively, the air bubble is maintained in the anterior chamber for a sufficient period. Nd:YAG laser suture lysis is performed after complete absorption of the air bubble during outpatient follow-up., Conclusions: Temporary pupil occlusion and retrolenticular air bubble injection provide a stable surgical approach in challenging cases of postvitrectomized unicameral eyes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Fibrin membrane pupillary-block glaucoma is an uncommon complication after phacoemulsification cataract surgery. We present a case treated successfully by pharmacological dilation of the pupil. Previous case reports have recommended the use of Nd:YAG peripheral iridotomy, Nd:YAG membranotomy and intracameral tissue plasminogen activator.The patient presented with intraocular pressure (IOP) of 45 mmHg 2 days after uneventful phacoemulsification cataract surgery. Anterior segment optical coherence tomography revealed that a fibrinous membrane-filled space had formed between the pupillary plane and the implanted intraocular lens.The diagnosis of fibrin membrane pupillary-block glaucoma was made. Initial treatment consisted of IOP-lowering medication and topical pupillary dilation (atropine 1%, phenylephrine hydrochloride 10% and tropicamide 1%). Within 30 min, the dilation broke the pupillary block and the IOP was 15 mmHg. The inflammation was treated with topical dexamethasone, nepafenac and tobramycin. Within a month, the patient reached a visual acuity of 1.0., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Reverse sulcus intraocular lens (IOL) implantation can cause serious ophthalmic complications. Even routine ocular examinations can provoke significant consequences. Herein, we present a case of recurrent pupillary capture and pseudophakic pupillary block related to reverse sulcus IOL implantation., Case Report: A 44-year-old man developed a pseudophakic pupillary block after pupil dilation aimed at relieving pupillary capture in an undetected reverse position of the sulcus IOL. The pupillary block was successfully treated with 2% pilocarpine and laser peripheral iridotomywas performed to prevent recurrence. The patient experienced recurrent pupillary capture with decreased vision in the affected eye. IOL exchange was the definite treatment resulting in improved vision and proper positioning of the IOL., Conclusions and Importance: When the reverse position of sulcus IOL is detected postoperatively, prophylactic laser peripheral iridotomy should be considered to prevent pupillary block particularly when pupillary capture is present. Pharmacologic pupillary dilation should be performed cautiously. Recurrent pupillary capture is possible and IOL repositioning should be considered to prevent further complications., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Pseudophakic pupillary block (PPB) was rare in patients who undergo phacoemulsification and posterior chamber intraocular lens (PCIOL) implantation. Laser peripheral iridotomy was the most reported but ineffective treatment in the literature., Methods: Retrospective, interventional case series of patients who developed PPB in Taipei Veterans General Hospital from 2017 to 2021. Clinical course, diagnostic methods, treatment and outcomes were recorded and discussed., Results: Four eyes of three patients were documented. All of them had diabetes and diabetic retinopathy. Anterior segment Optical coherence tomography (OCT) of these patients showed an exudative membrane at the peripapillary area while slit lamp image could not provide a clear view due to the severely edematous corneal condition. Laser peripheral iridotomy and yttrium aluminum garnet (YAG) laser aiming to the peripapillary exudation were applied to break the PPB successfully., Conclusion: Diabetes mellitus, intravitreal injection and inflammation are crucial risk factors for PPB. Anterior segment OCT can be a useful diagnostic tool for the detection of the peripapillary exudative membrane while corneal clarity is compromised due to high intraocular pressure. In addition to peripheral laser iridotomy, an effective approach to resolve PPB may be the use of the YAG laser to break the exudative membrane., Competing Interests: Declaration of Competing Interest All authors have declared no conflict of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Abstract: We present a case of ametropia corrected by small incision lenticule extraction (SMILE) in a corectopia eye after cataract surgery. The patient's optical zone, nomogram, and centration were carefully considered. The intended corrections were -6.60 - 1.25 × 175 OD and -6.85 - 0.50 × 10 OS. M-sized and S-sized cones were recorded in the right and left eye, respectively. The diameter of the right eye optical zone was 7.00 mm, whereas that of the left eye was 6.50 mm. The corneal vertex was determined using the film mark method as the scanning center. Three months after surgery, the uncorrected distance visual acuities were 20/20 OD and 20/13 OS. The effective optical zone was 6.5 and 5.5 mm in the right and left eyes, respectively. It is feasible to correct ametropia with SMILE in patients with corectopia after intraocular lens implantation. The large optical zone will compensate for the visual disturbance., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Contact Lens Association of Ophthalmologists.)

Purpose: To compare 6 methods for intraoperative pupil dilatation in eyes with insufficient pupil size during phacoemulsification., Methods: This was a prospective case-control study. 99 microcoria cataract patients (120 eyes) were collected and were divided into 6 groups(20 eyes each group), and their pupils were dilated by bimanual stretching pupil (group I), pupil radial cut open(group II), mechanical pupil dilatation with iris-retractor hooks (group III), OASIS iris expander (group IV), and Malyguin-ring (Microsurgical company, America) (group V), B-HEX Pupil Expander (Med Invent Devics, India)(group VI),respectively. 3.0 mm clear corneal incision were used in phacoemulsification. All cases were followed up at 1 week and 1, 3, 6 months after the surgery. The best corrected visual acuity (BCVA), intraocular pressure(IOP), corneal endothelium cell density(ECD), pupil diameter(PD) of before and after surgery were compared., Results: One same doctor finished all cataract surgeries successfully. The eyes' condition before surgery and at 6 months after surgery were compared. There were no significant statistical differences for the conditions of the eyes before surgery among six groups. The ECDs were better at 6 months postoperatively in group III and V, median values: 2114/mm 2 , 1961/mm 2 . PD was largest in group II (median value: 5.5 mm), which was significantly larger than other groups (P adjusted  < 0.05)., Conclusions: All 6 methods used in this study were effective for the mechanical dilatation of small pupils and didn't affect the postoperative visual acuity and intraocular pressure in microcoria cataract phacoemulsification. Iris-retractor hooks and the Malyugin Ring can reduce intraoperative corneal endothelium cell loss. Postoperative PD is larger when the iris was cut open radially., (© 2022. The Author(s).)

Abstract: A 42-year-old Algerian man presented for binocular oblique diplopia, hypersomnolence with drop attacks, bilateral hearing loss, and thoracic pain. He had a right thalamomesencephalic hemorrhage due to an underlying cavernous malformation treated with subtotal surgical resection. On neuro-ophthalmic examination, the patient had a left relative afferent pupillary defect and a right oculosympathetic efferent pupillary defect (i.e., Horner syndrome) in addition to other thalamomesencephalic eye and neurologic signs (right fourth nerve palsy, hearing loss, hemiparesis, and thalamic pain). Clinicians should recognize the localizing value of this unique constellation of mesencephalic afferent and efferent pupillary defects., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by North American Neuro-Ophthalmology Society.)

Pierson syndrome (PIERSS) is a rare autosomal recessive disorder characterized by the combination of congenital nephrotic syndrome (CNS) and extrarenal symptoms including ocular malformations and neurodevelopmental deficits. PIERSS is caused by biallelic pathogenic variants in the LAMB2 gene leading to the defects of β2-laminin, the protein mainly expressed in the glomerular basement membrane, ocular structures, and neuromuscular junctions. Severe complications of PIERSS lead to the fatal outcome in early childhood in majority of the cases. We report a case of 5-year-old girl with severe phenotype of PIERSS caused by biallelic functional null variants of the LAMB2 gene. Due to consequences of CNS, the patient required bilateral nephrectomy and peritoneal dialysis since early infancy. The course was additionally complicated by tubulopathy, life-threatening infections, severe hypertension, erythropoietin-resistant anemia, generalized muscular hypotonia, neurogenic bladder, profound neurodevelopmental delay, epilepsy, gastrointestinal problems, secondary hypothyroidism, and necessity of repeated ocular surgery due to microcoria, cataract, and nystagmus. Due to multidisciplinary efforts, at the age of 4 years, the kidney transplantation was possible. Currently, the renal graft has an excellent function; however, the girl presents severe neurodevelopmental delay. The report presents a unique long-term follow-up of severe PIERSS with a few new phenotypical findings. It highlights the clinical problems and challenges in management of this rare condition., (© 2021 S. Karger AG, Basel.)

Competing Interests: Competing interests: None declared.

Secondary angle closure in a pseudophakic eye due to pupillary block, more than a decade following phacoemulsification, has not been reported. We managed a 75-year-old female presenting with sudden, painful diminution of vision and raised intraocular pressure in the right eye. The key finding was an almost flat anterior chamber with intraocular lens in normal position clinically as well as on ultrasound biomicroscopy. The posterior chamber was ballooned up by vitreous, which was cleared surgically to restore the anatomy. Meticulous clinical examination augmented by ultrasound biomicroscopy findings helped us to diagnose and manage this case for satisfactory intraocular pressure and visual outcome.

Purpose: The authors report a rare complication of "pseudophakic reverse pupillary block" after a secondary, scleral-fixated intraocular lens implantation using the Yamane technique., Methods/results: A 52-year-old male patient was referred for uncontrolled intraocular pressure (IOP) despite 3 topical antiglaucoma medications in his right eye (RE). Elevated IOP occurred after the RE cataract surgery performed elsewhere 1 year ago. On examination, the RE visual acuity was 20/60, IOP was 28 mm Hg, the iris showed mid-peripheral transillumination defects with iris chaffing, posterior bowing of the iris with a deep anterior chamber, pigment dispersion, and scleral-fixated intraocular lens (SFIOL). Ultrasound biomicroscopy showed a deep anterior chamber with posterior bowing of iris with concave iris configuration with iridolenticular contact with the SFIOL, suggestive of reverse pupillary block. After laser peripheral iridotomy, the iris moved forward into planar position, iridolenticular contact was relieved with a resolution of the pupillary block, and the IOP reduced to 14 mm Hg., Conclusions: The present case describes a rare complication of "pseudophakic reverse pupillary block" after a glued SFIOL implantation. The probable mechanism for the pupillary block is the reduced gap between the posterior surface of iris and optic of the IOL. This is likely caused by the loss of 5-degree posterior angulation of the 3-piece IOL because of stretching of the haptics leading to an increase in the iridolenticular contact and reverse pupillary block and elevated IOP. The persistent anterior chamber inflammation as a result of iris chaffing and pigment dispersion could also contribute to compromised trabecular outflow and further IOP elevation.Reverse pupillary block can occur after a glued SFIOL implantation that can be relieved by a laser peripheral iridotomy. The authors recommend either preoperative laser peripheral iridotomy or surgical iridectomy intraoperatively in eyes with a glued intraocular lens to prevent this rare complication.

Purpose: To report a unique case of acute angle closure glaucoma in the setting of a subarachnoid hemorrhage due to a ruptured cerebral aneurysm., Materials and Methods: Observational case report and review of the literature., Results: A 75-year-old woman presented with blurry vision, nausea, vomiting, and left eye pain. She was found to have a complete third nerve palsy, with ptosis, exotropia, hypotropia, and a fixed mydriasis with resultant acute angle closure glaucoma. Pilocarpine was initiated, and neuroimaging revealed a subarachnoid hemorrhage from a ruptured posterior communicating artery aneurysm. The aneurysm was successfully coiled, and outpatient laser iridotomies were subsequently performed. Only 4 prior cases of acute angle closure glaucoma in the setting of a third nerve palsy have been reported in the literature. To our knowledge, this case is the first report of angle closure glaucoma in the setting of a subarachnoid hemorrhage., Conclusions: This case of a complete third nerve palsy in the setting of a subarachnoid hemorrhage leading to acute angle closure highlights the importance of ruling out this life-threatening diagnosis when neurological signs of increased intracranial pressure and cranial nerve palsies are present.

A 7-year-old girl presented with watering and redness in the left eye for 2 months. Her parents reported poor vision in both eyes for 4 years. Visual acuity was finger counting at 1 m and finger counting close to face in the right and left eyes, respectively. Slit lamp examination of the right eye revealed corectopia, aphakia in the pupillary area, temporally subluxated clear crystalline lens, persistent pupillary membrane, irido-hyaloidal adhesion and poorly dilating pupil. Left eye revealed central corneal oedema with descemet scarring, anteriorly dislocated clear crystalline lens with lenticulo-corneal touch. Ultrasound examination of the left eye was normal. Hence a diagnosis of ectopia lentis et pupillae with left eye spontaneous anterior dislocation of the lens along with corneal decompensation was made. The child underwent microscope integrated intraoperative optical coherence tomography guided intralenticular lens aspiration with optical iridectomy in the left eye. Postoperative visual rehabilitation was done with aphakic glasses., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To demonstrate the efficacy and initial results of single-pass four-throw pupilloplasty in cases of Urrets-Zavalia syndrome., Methods: In this prospective interventional study, single-pass four-throw was performed to reconstruct the pupil in all symptomatic cases with Urrets-Zavalia syndrome. Applanation tonometry, indentation gonioscopy, and anterior segment optical coherence tomography for anterior chamber angle assessment were performed in all the cases., Results: Out of 10 cases that were identified with Urrets-Zavalia syndrome, the procedure was performed in 7 cases, whereas 3 cases were left untreated, as they did not have any visual complaints. Five out of seven eyes had preoperative raised intraocular pressure with appositional closure of the angle. Postoperatively, intraocular pressure was controlled in all the eyes, whereas one eye required antiglaucoma medications to control the intraocular pressure. The mean preoperative and postoperative best-corrected visual acuity was 1.1 ± 1.2 and 0.4 ± 0.4 LogMar, respectively. There was a significant improvement in the best-corrected visual acuity (p = 0.0169) in the postoperative period. The mean preoperative and postoperative intraocular pressure was 26.6 ± 11.23 and 16.3 ± 2.98 mm Hg, respectively (p = 0.0168). All the patients had a minimum of 6-month follow-up period (range = 6-8 months)., Conclusion: Single-pass four-throw can be employed for cases with Urrets-Zavalia syndrome, and single-pass four-throw helps to prevent the postoperative glare and narrows down the pupil size effectively. Single-pass four-throw helps to alleviate the anterior chamber angle apposition in patients with Urrets-Zavalia syndrome by mechanically pulling the peripheral iris centrally as demonstrated on anterior segment optical coherence tomography. The study also reports the occurrence of Urrets-Zavalia syndrome after glued intraocular lens surgery.

Background: To describe a technique of surgical peripheral iridectomy via a clear-cornea tunnel incision to prevent or treat pupillary block following phacoemulsification., Methods: Description of technique and retrospective description results in 20 eyes of 20 patients with acute angle closure with coexisting visually significant cataract undergoing phacoemulsification considered at risk of postoperative papillary block as well as two pseudo-phakic eyes with acute postoperative pupillary-block. Following phacoemulsification and insertion of an intraocular lens, a needle with a bent tip was inserted behind the iris through the corneal tunnel incision. A blunt iris repositor was introduced through the paracentesis and placed above the iris to exert posterior pressure and create a puncture. The size of the puncture was enlarged using scissors. For postoperative pupillary block the same technique was carried out through the existing incisions created for phacoemulsification., Results: Peripheral iridectomy was successfully created in all 22 eyes. At a mean follow-up of 18.77 ± 9.72 months, none of the iridectomies closed or required enlargement. Two eyes had mild intraoperative bleeding and one eye a small Descemet's detachment that did not require intervention. No clinically significant complications were observed. Visual acuity and IOP improved or was maintained in all patients. The incidence of pupillary block in our hospital was 0.09% overall, 0.6% in diabetics and 3.5% in those with diabetic retinopathy., Conclusions: This technique of peripheral iridectomy via the cornea tunnel incision can be safely used during phacoemulsification in eyes at high risk of pupillary block or in the treatment of acute postoperative pupillary-block after cataract surgery. The technique is likely to be especially useful in brown iris, or if a laser is not available.

Purpose: To analyze risk factors and management of pupillary intraocular lens (IOL) capture after IOL transscleral fixation., Setting: Department of Ophthalmology, Seoul National University Hospital, Seoul, South Korea., Design: Retrospective case series., Methods: A chart review was performed of patients who had transscleral fixation of IOLs between January 1, 2012, and December 31, 2013. Eyes were divided into 2 groups depending on whether the IOL was pupillary captured. Perioperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), spherical equivalent (SE) with refraction, axial length (AL), and total follow-up time were compared between the 2 groups. Ultrasound biomicroscopy images were used to analyze iris morphology and IOL position., Results: The chart review identified 138 patients, 112 patients of whom were included in this analysis. The preoperative and final mean CDVA, IOP, SE, AL, and most iris morphologic parameters were not significantly different between the 2 groups. In the pupillary capture IOL group, the mean age of patients with was younger, the anterior chamber depth (ACD) was narrower, and the rate of reverse pupillary block was higher (P = .003, P = .03, and P = .016, respectively). Intraocular lens decentration in the captured group was significantly larger (P = .002). Multiple logistic regression analysis showed that ACD, reverse pupillary block, and main decentration were associated with pupillary capture of the IOL., Conclusions: Pupillary capture of an IOL occurred more in eyes with reverse pupillary block and poor IOL positioning. Accordingly, laser iridotomy must be considered for treatment., (Copyright © 2017. Published by Elsevier Inc.)

A 28-year-old woman had uneventful implantation of a phakic intraocular lens (pIOL) in her left eye (Visian ICL, EVO+ model, 13.2, -7.50 diopters) to correct myopia. Six days after the procedure, she presented with herniation of the iris. Surgical reduction was carried out successfully through the previous peripheral corneal paracentesis. On the following day, the patient reported ocular pain and blurry vision. Examination showed a shallow anterior chamber, moderate diffuse corneal edema, and ocular hypertension. The central port of the pIOL was blocked by iris pigment. The condition resolved completely after surgical iridectomy, and the postoperative course was uneventful. To our knowledge, this is the first reported case of pupillary block after implantation of a pIOL with a central hole. This uncommon complication should be taken into consideration when the iris is manipulated excessively after pIOL insertion., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the outcomes and tolerance of micronized mineral pigments for corneal tattooing, using a superficial automated keratopigmentation (SAK) technique in an experimental animal model and a new puncture device to inject the pigments into the corneal stroma., Methods: Forty eyes of 40 New Zealand rabbits were included in this study. The animals were divided into groups A and B. Both groups underwent SAK using a new automated keratopigmentation device. Micronized mineral pigments were injected through the epithelium into the corneal stroma to replicate the iris color in 25 eyes (group A), and black color was used to replicate the pupil in 15 eyes (group B). Slit-lamp examination was performed to evaluate the outcome. Histopathological examination was also performed to ascertain the presence of pigment dispersion, inflammation, and/or neovascularization., Results: All 40 eyes showed good cosmetic appearance after keratopigmentation. No intraoperative complications were detected. At the first week, mild or moderated conjunctival injection was observed in 13 eyes and transitory corneal epithelial defects were also detected in 27 eyes. Examination was unremarkable 2, 4, and 6 months after surgery. No neovascularization was detected in any case in the histopathology study., Conclusions: SAK using a new automated puncture device and micronized mineral pigments achieved good cosmetic outcomes for iris and pupil simulation. This method could be a valid alternative to treat serious cosmetic eye problems that affect the superficial cornea or functional problems, such as photophobia or diplopia secondary to iris defects or trauma.

Purpose: To describe a surgical technique for performing pupilloplasty., Methods: In this surgical technique for pupilloplasty, after a single pass of needle through the edges of iris defect along the pupillary margin, the suture end is passed through the loop with 4 throws, creating a helical configuration in modified Siepser slipknot technique that is self-retaining and self-locking., Results: The technique was performed in 27 cases and the loop did not open in any of the cases in the 6-month follow-up period. No case of iritis was seen. The iris tissue was seen well approximated to each other in all cases., Conclusions: The single-pass 4-throw technique serves as an effective method to perform pupilloplasty.

Purpose: To describe the incidence, risk factors, and management of pupillary abnormalities after anterior chamber (AC) full air or gas tamponade in Descemet membrane endothelial keratoplasty (DMEK) without pupillary block., Methods: In this retrospective case series, clinical records of 25 patients (32 eyes) who underwent DMEK were reviewed for pupillary abnormalities and iris morphology. All patients had nearly full intracameral tamponade with air or 20% SF6 at the end of surgery without default air release postoperatively., Results: Pupillary abnormalities ranging from mild ovalization to mid-mydriasis were seen in 56% of the cases. These abnormalities were not related to morphometric changes in the iris volume, or in the iris dilator or iris sphincter muscle, but were probably due to posterior synechiae. Combining DMEK and cataract surgery increases by 5-fold the odds of developing this complication. Surgical revision of the posterior surface of the iris and synechiolysis reversed these pupillary abnormalities., Conclusions: Nonischemic pupillary abnormalities can be seen in patients with DMEK using a nearly full air/gas tamponade in the AC after surgery despite patent iridectomy especially when combined with cataract surgery. Ensuring complete mydriasis in the immediate postoperative period and a free-floating bubble in the AC above the inferior pupillary margin may reduce its incidence.

Background: Few studies have established surgical landmarks for endoscopic endonasal dissection of the intraconal orbital apex (OA)., Objective: We describe the optic nerve (ON) anatomy and its relationships, as seen during a fully endoscopic, endonasal approach to the medial intraconal OA., Methods: The study question was approached through a cadaver dissection and a radiographic study. Four formalin-fixed, latex-injected cadaver heads were dissected using transnasal endoscopic techniques. Dissection was performed using 0 degree and 30 degree nasal endoscopes and standard endoscopic sinus surgical instrumentation. A bi-nostril 4-handed technique was used. The anatomy of 8 medial OAs was evaluated and recorded. As the radiographic portion, 100 consecutively enrolled patient magnetic resonance images were evaluated, with particular attention given to the relationship of the ON to the medial rectus muscle (MRM) in 200 orbits., Results: Intraconally, the ON consistently coursed along the superior half of the MRM. Interestingly, the nerve was more easily identified from a superior approach after retracting the MRM inferiorly. With the identification of the nerve at the OA, carrying the dissection of the medial OA was easily accomplished with the ON as the guiding landmark. The radiographic portion of this study revealed a consistent relationship between the superior edge of the ON and the MRM. This relationship was maintained in the orbital apex in 98.4%-100% of the orbits examined., Conclusion: The superior edge of the optic nerve is consistently found coursing along the superior half of the MRM, facilitating facile identification and further dissection navigation., (Copyright © 2016 by the Congress of Neurological Surgeons)

A 2-month-old boy presented with an irregular left pupil. Over the course of 3 months, progressive pupil ovalization, corectopia, and ballooning of the thinned superior iris tissue caused obstruction of the visual axis. Because of concern for deprivational amblyopia, a sectoral pupilloplasty and sphincterotomies were performed, restoring pupil shape and clearing the visual axis. On postoperative examinations, the pupil remained round, the visual axis clear, and visual acuity of the left eye improved. Findings and clinical course suggested the diagnosis of idiopathic tractional corectopia, a rare congenital disorder of unknown cause that may lead to isolated unilateral progressive corectopia and visual axis obstruction. Patients should receive regular follow-up examinations., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: This case report describes the surgical technique of trabeculectomy, mechanical separation of the iris from the cornea, and creation of a pupillary aperture by an automated vitrector in a child with newborn glaucoma with imperforate pupil., Case Report: A 1-month-old child was referred to us with the diagnosis of congenital glaucoma of the left eye. Examination under anesthesia revealed megalocornea (corneal diameter, 12 mm) with corneal edema of the left eye whereas the right eye was normal. Intraocular pressure was 8 and 26 mm Hg in the right eye and left eye, respectively. Examination under anesthesia revealed imperforate pupil with uveal tissue attached on the back surface of the left cornea whereas the iris and the pupil of the right eye were normal. A diagnosis of newborn glaucoma and imperforate pupil of the left eye was made and the child underwent trabeculectomy, mechanical separation of the iris from the back surface of the cornea, and creation of pupillary aperture by an automated vitrector. The child had an uneventful postoperative course with disappearance of corneal edema, but there were several linear scars across the cornea. The child completed 3 years of follow-up and his best spectacle corrected visual acuity in the left eye was 20/32 and the intraocular pressure was 10 mm Hg in both eyes., Conclusions: The surgical technique was safe and effective in the restoration of corneal clarity and creation of the pupillary aperture with good visual recovery.

Purpose: To present cases of uveitis-glaucoma-hyphema (UGH) syndrome due to reverse pupillary block in sulcus-placed posterior chamber intraocular lenses (PC IOLs) that were managed with laser peripheral iridotomy (LPI)., Setting: Community-based subspecialty clinics., Design: Retrospective interventional case series., Methods: A chart review of patients with a sulcus-placed PC IOLs presenting with UGH syndrome and reverse pupillary block with posterior iris bowing as diagnosed by gonioscopy and anterior segment optical coherence tomography was carried out. Laser peripheral iridotomy was performed in the eyes included in the study. The main outcome measure was clinical resolution of UGH syndrome., Results: The study included 6 eyes of 6 patients with a mean age of 59.8 years (range 43.0 to 66.0 years) who presented with unilateral UGH syndrome a mean of 28.7 months (range 0.3 to 84.0 months) after PC IOL implantation. All patients were previously myopic, with 5 (83.3%) having a history of vitrectomy. The mean axial length was 27.0 mm ± 1.4 (SD). An LPI was used to treat the reverse pupillary block with resultant improvement in iris profile and resolution of UGH syndrome in all eyes. The mean intraocular pressure decreased from 30.5 ± 10.0 mm Hg on 0.5 ± 0.8 glaucoma medications to 15.5 ± 3.2 mm Hg postoperatively on 0.7 ± 1.2 medications., Conclusions: The UGH syndrome due to reverse pupillary block occurred after sulcus-placed PC IOLs in susceptible patients, those with axial myopia, and post-vitrectomized eyes. The cases were managed with LPIs., Financial Disclosure: Dr. Ahmed is a consultant to Alcon Laboratories, Inc. and Abbott Medical Optics, Inc. No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

A 20-year-old woman, a registered nurse, presented with best-corrected visual acuity of 6/15 (20/50) due to bilateral extensive persistent pupillary membrane. Sequential argon laser photocoagulation of the iris strands at the pupillary membrane iris collarette followed by neodymium:YAG laser lysis resulted in partial clearing of the central visual axis without bleeding. Best-corrected visual acuity improved to 6/9 (20/30) bilaterally without complications noted 1 year after combined laser therapy., (2015 BMJ Publishing Group Ltd.)

Frequently, in literature and curent practice, accessory iris membrane (AIM) and persistant pupillary membrane (PPM) are confused. Both AIM and PPM are congenital iris anomalies in which fine or thick iris strands arrise form the collarette and obscure the pupil. AIM, which is also called iris duplication, closely resembles the normal iris tissue in color and thickness and presents a virtual second pseudopupil aperture in the centre while PPM even in its extreme forms presents as a translucent or opaque membranous structure that extends across the pupil and has no pseudopupil. Mydriatiscs, laser treatment or surgery is used to clear the visual axis and optimize visual development. Surgical intervention is reserved for large, dense AIMs and PPMs. Our patient, a 29 year old male, has come with bilateral dense AIM, bilateral compound hyperopic astigmatism, BCVA OD = 0.6, BCVA OS = 0.4, IOP OU = 17 mmHg. To improve the visual acuity of the patient we decided to do a bilateral membranectomy, restoring in this way transparency of the visual axis. After surgery, the visual acuity improved to BCVA OD= 0.8, BCVA OS=0.8.

Purpose of Review: To summarize the multiple mechanisms responsible for angle closure in uveitis and to outline the management principles and treatment modalities., Recent Findings: Angle closure in uveitis is a heterogeneous disease with multiple mechanisms. Recent advances in anterior segment imaging have provided insights into the mechanisms of angle closure in uveitis. Uveitic eyes with angle closure from pupil block require surgical iridectomy with mobilization of the peripheral iris and viscogoniosynechiolysis of both posterior synechiae and peripheral anterior synechiae. Systemic conditions associated with uveitis can result in anterior displacement of the iris-lens diaphragm, and present as acute angle closure. Pupil block is not the predominant mechanism in these eyes, and management is primarily medical. Data are limited on the optimal treatment of angle closure in uveitis, and the role of glaucoma filtration surgery, cataract extraction, minimally invasive glaucoma surgery and newer modalities of cycloablation require evaluation., Summary: The management of angle closure in uveitis should adhere to the principles of managing both uveitic glaucoma and angle closure. Identification of the mechanism of angle closure in uveitic eyes may enable treatment to be targeted at the responsible mechanism.

Unlabelled: We describe a simple surgical technique to manage pupillary capture after previous transscleral fixation of an intraocular lens., Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Background: Infants with hyperplastic persistent pupillary membranes (PPM) may be at risk for deprivation amblyopia due to obstructions of the visual axis. We describe the long-term visual and anatomic outcomes of a surgical technique for their removal., Methods: The medical records of consecutive patients <3 years of age who underwent surgical removal of PPMs between December 1998 and May 2012 were retrospectively reviewed. Each PPM was judged to be visually significant based on poor visual acuity, poor retinoscopic reflex, or inability to visualize the fundus. The surgical technique included injection of a viscoelastic agent beneath the pupillary strands to bow them anteriorly, careful peeling of residual adherent strands from the anterior lens capsule, and lysis of the strands at the pupillary margin with intraocular scissors. Pre- and postoperative visual and anatomic results were recorded., Results: This case series included 10 eyes of 6 patients: PPMs were bilateral in 4 patients and unilateral in 2. The patient age at time of surgery ranged from 2.5 months to 2.5 years (mean, 14 months). Mean postoperative follow-up was 5.3 years (range, 2.5-8 years). All patients had successful clearance of the visual axis and good visual acuity. No intraoperative complications occurred., Conclusions: All patients in this series had excellent visual and structural outcomes, with no significant complications. The technique described here may be considered for patients with visually significant PPMs to improve visual function and pupil appearance., (Copyright © 2014 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

The article studies application possibilities and potency of near infrared coagulative radiation of a diode laser for correction of postoperative iris defects followed by pupillary deformities and displacement. It is found that the use of near infrared diode laser radiation at 0.810 microm enables visual improvement through pupil enlargement or its shift to the optical centre. The use of the wavelength specified does not cause severe atrophic or cosmetic changes in the iris.

Superior ophthalmic vein (SOV) thrombosis is a rare complication of carotid-cavernous fistula (CCF) embolization and is usually associated with a paradoxical worsening of signs followed by subsequent spontaneous resolution. We report a case in a 69-year-old female who developed orbital compartment syndrome due to SOV thrombosis following transvenous embolization of an indirect CCF. The patient was treated with an urgent lateral canthotomy and cantholysis and had good recovery. This report demonstrates that the paradoxical worsening due to SOV thrombosis in CCF may result in orbital compartment syndrome and require early recognition and prompt decompressive measures to avoid permanent visual sequelae.

A 61-year-old man with high myopia who had received a systemic α1A-adrenoceptor antagonist had phacoemulsification and in-the-bag intraocular lens implantation in the right eye. One day postoperatively, marked pigment dispersion in the anterior chamber, posterior bowing of the iris, and iridodonesis were noted associated with a subsequent elevation in intraocular pressure (IOP). Pharmacological pupil dilation was effective in reducing pigment dispersion and IOP, and laser peripheral iridotomy was performed to alleviate posterior bowing of the iris. We hypothesize that dynamic changes in the aqueous humor flow by cataract surgery and latent flaccidity of the iris due to the systemic α1A-adrenoceptor antagonist caused reverse pupillary block. High myopia may be another risk factor for this complication., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

We report a case in which laser-assisted cataract surgery was performed safely and successfully following manual division of posterior synechiae and mechanical dilation of the pupil with a Malyugin ring in a patient with an irregular, small stuck-down pupil., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Unlabelled: We describe a patient who required surgical explantation of a phakic intraocular lens (pIOL) as a result of mechanical angle closure despite the absence of standard preoperative risk factors. An assessment of the patient's records suggested peripheral anterior chamber depth (ACD) values considerably shallower than the central ACD measurement. Subsequently, the midperipheral values of all patients having pIOL implantation at our practice were reviewed to provide potential baseline measurements for comparison against the values of the explanted pIOL eyes. Assessment of midperipheral anterior chamber anatomy may be advantageous in the evaluation of patients for pIOL surgery., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the efficacy of different treatment modalities in eyes with small pupils before femtosecond laser-assisted cataract surgery., Setting: Ruhr University Eye Clinic, Bochum, Germany., Design: Prospective clinical trial., Methods: Eyes with an intraoperative pupil size smaller than 5.5 mm received sequential treatments to achieve a pupil larger than 5.5 mm in 3 steps: (1) intracameral administration of epinephrine solution, (2) additional viscomydriasis, and (3) implantation of a Malyugin ring pupil expander. When a step enlarged the pupil to at least 5.5 mm, femtosecond laser-assisted cataract surgery with an anterior capsulotomy diameter of at least 4.5 mm and 350 μm nuclear fragmentation grids, ultrasound phacoemulsification, and intraocular lens implantation were performed. Main outcome measures were achieved preoperative pupil size in each sequential treatment group and analysis of intraoperative complications., Results: Of 850 eyes scheduled for cataract surgery, 40 received sequential treatments. To achieve a pupil larger than 5.5 mm, epinephrine was sufficient in 7% of the eyes; additional viscomydriasis was necessary in 25%, and the pupil expander was implanted in 68%. The most frequent comorbidities were pseudoexfoliation of the lens capsule (30.0%) and intraoperative floppy-iris syndrome (12.5%). Tongue-like lesions of the capsulotomies were detected in 5 eyes., Conclusions: The 3-step treatment allowed the surgeon to increase the efficiency and safety of femtosecond-assisted cataract surgery in eyes with a small preoperative pupil, providing good safety margins at the pupil boundary for the capsulotomy and the softened nuclear volume., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)