Grand ward round the iris that was not there
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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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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

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


Examination finds

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+


Grand ward round the iris that was not there

Anterior Segment Photos

Left Eye

Right Eye


Examination finds1

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


His family s story

His Family’s Story …

70

64

 

  

34

33


Clinical assessment

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


Management options

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.


Video

video


Postop anterior segment photo

Postop anterior segment photo


Postoperative outcome

Postoperative Outcome …

  • VA Right eye :

    6/120 POD1 6/45 POM1

  • IOP normal

  • Subjective satisfactory reduction of glare


Cataract surgery combined with implantation of an artificial iris

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


Purpose

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


Cases of congenital aniridia

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


Cases of congenital aniridia1

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


Cases of congenital aniridia2

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


Cases of traumatic aniridia

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


Cases of traumatic aniridia1

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


Cases of traumatic aniridia2

Cases of traumatic aniridia

Case 2


Case of secondary chronic mydriasis

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


Learning points

Learning points …

Need for artificial iris rings established

Endocapsular fixation possible

Yes

No

50C

67F

But need a larger wound

96G


Learning points1

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


Learning points2

Learning points …

  • Other uses of artificial iris diaphragm:

    • Preventing silicone-endothelial contact after VR surgery


Thank you

Thank you


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