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In the Dec. 10, 2023, issue of Healio | OSN, Binotti and Alwreikat present an interesting trauma case: a man falling and hitting his face.
The pseudophakic left eye had reduced vision (20/50) with no major findings except subconjunctival hemorrhage, hyphema and aniridia, with a slightly elevated IOP. The differential diagnosis in such cases is whether the injury is a rupture or a contusion. Indirect signs pointing to contusion include the mild visual loss, the lack of a visible corneoscleral wound, the preserved capsular bag/IOL despite the “loss” of the iris, and the lack of a severe intravitreal hemorrhage. The authors decided, correctly, to do explorative surgery (despite a negative CT) and found no wound beneath the subconjunctival hemorrhage. The diagnosis of contusion has thus been confirmed.
Image: Adobe Stock
However, the “aniridia” finding requires careful further consideration. The fact that the iris has not been expelled (as it could have been in case of a rupture) and that the capsular bag/IOL complex has not been dislocated points to a different diagnosis: total retraction of the iris. The tissue is not missing; it is withdrawn toward the scleral spur, held there by blood and a fibrin “glue.” This is not aniridia but an extreme form of dilatation.
This condition is not rare after a severe contusion; if the ophthalmologist performs an exam at the slit lamp with scleral depression, the iris immediately becomes visible.
In such cases, the only effective therapy is immediate surgery. The surgeon needs to use serrated forceps to gently pull on the iris margin 360° and, if possible, use a blunt tool such as a spatula to break the fibrin on the back surface of the iris. In the case presented in Healio | OSN, the eye was pseudophakic, which allows the maneuver to be carried out because there is no risk to the crystalline lens. In a phakic eye, there is a dilemma requiring the surgeon to make an individualized decision whether to omit cleansing the iris’ back surface (this threatens with recurrence of the retraction) or go ahead with it (this risks lens damage, even if viscoelastics are used).
If the iris is left in its retracted position, within a few days this becomes an irreversible condition with resulting photophobia. Should the eye have decent vision, an iris prosthesis will probably need to be implanted eventually, a rather complex and expensive surgery. Early and proper intervention to counter the iris retraction will prevent this cascade of events.
Ferenc Kuhn, MD, PhD
Chairman, International Society of Ocular Trauma
Director of research, Helen Keller Foundation for Research and Education
Professor, Department of Ophthalmology University of Pécs Medical School, Hungary
The authors respond:
We thank Dr. Kuhn for his comments on our case report.
Dr. Kuhn highlights an important albeit rare differential diagnosis, ie, total iris retraction, one should consider when faced with patients who have suffered ocular trauma. A careful examination to identify any iris tissue damage is necessary, especially in the presence of hyphema, to assess for early intervention, as mentioned by the author. In our case, the superior portion of the angle was clearly visible on slit lamp examination, which showed intact ciliary bodies, capsular bag and centered IOL. No iris tissue was visualized on slit lamp, gonioscopy or indirect ophthalmoscopy with gentle scleral depression. There was, however, iris pigment and fragments identified on the inferior eyelashes and a strand of coagulated blood adhered to the inner portion of the previous surgical corneal wound, suggesting an extrusion of intraocular content through the wound and subsequent self-sealing once IOP and anatomy were restored.
Furthermore, once the hyphema resolved, a repeat full eye examination showed an aniridic left eye with signs of avulsion at the root of the iris and no visible iris tissue intraocularly. It is important to highlight that there was no retinal detachment, vitreous hemorrhage, or significant IOL decentration or tilt. The patient’s vision was stable 3 months after trauma. Overall, our findings corroborate with a complete iris avulsion likely secondary to a sudden decompression of the anterior chamber caused by the fall and trauma to the face/eye, as previously reported in the literature. We again thank Dr. Kuhn for his insightful comments and thoughtful suggestions.
Amal Alwreikat, MD
Cornea specialist
Lahey Hospital and Medical Center Burlington, Massachusetts
William Binotti, MD
Ophthalmology resident
Tufts Medical Center, Boston
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