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Man experiences pain, decreased vision after being hit in face
In the left eye, there was a significant anterior chamber reaction with a microhyphema and extensive damage to the iris.
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A 26-year-old man presented to the emergency department after being struck on the left side of his face with a hockey stick. He immediately experienced left eye pain and decreased vision; however, he did not lose consciousness. His ocular history was unremarkable except for being a contact lens wearer. He had no significant medical history.
Figure 1. Anterior segment photograph of the left eye showed a large iridodialysis and a consolidated anterior chamber hemorrhage.
Images: Lee G, Wu HK
Examination
The patient’s best corrected visual acuity was 20/20 in the right eye and hand motion in the left eye. On external examination, he had a 3-cm-deep penetrating laceration of his left upper eyelid at the junction of the superior orbital rim and nasal bone. There was significant ecchymosis with moderate edema. His right pupillary response was briskly reactive, but his left pupil was fixed in an irregular shape. IOP was 14 mm Hg in the right eye and 19 mm Hg in the left eye.
On slit lamp exam, there was mild conjunctival injection of the left eye, but the cornea was clear without evidence of laceration or rupture. There was a significant anterior chamber reaction with a microhyphema and extensive damage to the iris (Figure 1). The lens capsule appeared intact. There was no view to the posterior pole, but B-scan showed a vitreous hemorrhage without retinal detachment or intraocular foreign body. The right eye was unremarkable. CT scan of the orbits showed no orbital fracture but identified a hyperlucent foreign body in the periorbital space in the area of the deep laceration.
What is your diagnosis?
Irregular pupil
The differential diagnosis for an irregular pupil after trauma included an iris sphincter tear, traumatic iridodialysis and a peaked pupil with a ruptured globe. Of these, a ruptured globe must always be ruled out at the time of injury because immediate surgical intervention would need to be planned to repair the globe. Based on the patient’s clinical findings of a well-formed anterior chamber, normal IOP, and lack of laceration or extensive subconjunctival hemorrhage, he was diagnosed with traumatic iridodialysis.
Treatment
The patient was started on prednisolone acetate 1% for his anterior chamber inflammation and microhyphema. He also underwent repair of his eyelid laceration with exploration but no identification of a foreign body. Although his IOP remained normal initially, the patient was also started on Cosopt (dorzolamide hydrochloride 2%, timolol maleate 0.5%, Merck) due to presumed damage to his drainage angle. However, 3 days after his injury, IOP increased to 42 mm Hg. He was immediately started on other pressure-lowering medications, including Alphagan P (brimonidine tartrate ophthalmic solution, Allergan), Travatan (travoprost, Alcon) and oral acetazolamide. His pressure improved to 18 mm Hg, and he was discharged home.
Figure 2. One month later, the patient had evidence of zonular loss and an early posterior subcapsular cataract.
Figure 3. Fundus photo of the left eye at month 1 showed a small area of macular commotio near the fovea.
Figure 4. OCT of the left macula demonstrated edema in the photoreceptor layer and slight distortion of the IS/OS junction, consistent with macular commotio.
Figure 5. Anterior segment photograph of the left eye 1 day after iridodialysis repair. All but 2 clock hours of the iris were able to be repaired.
One month after the trauma, the patient’s visual acuity was 20/70 in the left eye without correction, but he had to look eccentrically around the damaged iris. His anterior chamber was quiet, and his IOP was normal on one medication. He had persistent iridodialysis from 10 o’clock to 4 o’clock with intact iris root structures but evidence of angle recession on gonioscopy. There was also visible vitreous prolapse into the anterior chamber in an area of broken zonules (Figure 2). Dilated fundus exam revealed a small area of parafoveal whitening consistent with macular commotio (Figure 3), and optical coherence tomography of the macula showed findings of outer retinal edema in the area of clinical whitening (Figure 4).
Due to persistent visual difficulties secondary to the position of the traumatized iris, it was decided to go forward with repair of the iridodialysis at that time.
Discussion
Iridodialysis is a separation of the iris from its attachment to the ciliary body. It is usually caused by blunt trauma to the eye but can be caused by penetrating injuries. Small dialyses may be asymptomatic and not require treatment, but patients with larger dialyses may experience monocular diplopia, glare or photophobia due to corectopia or polycoria. They are often also associated with angle recession, glaucoma and hyphema.
Early treatment usually includes management of the hyphema with bed rest and monitoring of the hemorrhage and IOP. Later, surgical repair is considered for larger, more symptomatic dialyses.
Historically, there have been numerous methods of iridodialysis repair with varied success. Open-chamber techniques involve creation of a large full-thickness scleral incision and retrieval of the iris edge, which is then sutured to the sclera. This type of repair is associated with increased astigmatism and potential wound instability, especially in patients such as ours who had a large dialysis. Furthermore, by exposing the uveal tissue in an open-chamber technique, the patient is placed at higher risk for sympathetic ophthalmia.
Closed-chamber techniques have also been described. McCannel developed a 17-mm straight needle with 10-0 polypropylene suture that is used to pass through the limbus close to the site of injury, then through the torn iris, and back again through the limbus with retrieval of the suture ends through a paracentesis. The suture is then tied from outside the anterior chamber, and the iridodialysis is closed. For larger dialyses, many other techniques may be employed. Specifically, this patient underwent repair with the Snyder technique. It is a modified method of one initially described by Wachler et al using a cross-pupil approach with a double-armed McCannel suture. One at a time, each needle enters through the same paracentesis 180° from the iridodialysis, through the torn edge, and then through the sclera 2 mm to 4 mm away from each other. The ends are then tied tight to the sclera. The Snyder method, in contrast, tightens the torn iris edge close to but not tight against the internal scleral wall or iris root. This is intended to preserve the trabecular meshwork because these patients are usually already at high risk for glaucoma secondary to the nature of the trauma. This patient also underwent a limited anterior vitrectomy with staining of the vitreous by triamcinolone.
Conclusion
Postoperatively, the patient had 20/20 vision in his left eye with correction and normal IOP on medication. While happy with his cosmetic and visual result, he had residual iridodialysis for 2 clock hours where the iris was too fragile to keep a suture (Figure 5). He remains on Cosopt and Alphagan, and he will need continued glaucoma follow-up for angle recession. He is also being followed for an increasing cataract and may have repair of his remaining iridodialysis at the time of cataract extraction.