112 AMERICAN JOURNAL OF OPHTHALMOLOGY JULY, 1983

HYPOTONY AS A LATE COMPLICATION OF EXTRACAPSULAR CATARACT EXTRACTION

O R N A G E Y E R , M.D. , V I C T O R G O D E L , M.D. , AND M O S H E LAZAR, M.D.

Department of Ophthalmohgy, Ichilov Hospital, Tel Αυίυ University Medical School, Tel Aviv, 64239, Israel (Dr. Lazar)

Persistent hypotony after extracapsular cataract extraction is an uncommon but significant complication. We observed an unusual late complication of extracapsular cataract extraction—detachment of the ciliary body and the choroid caused by traction of lenticular remnants adherent to the intact posterior capsule.

A 40-year-old woman with a cataract underwent a phacoemulsification proce­dure. Almost all the cortical material was aspirated. Peripheral iridectomy was per­formed and the posterior capsule was left intact. The operation and the postopera­tive course were uneventful. The patient was treated with topical corticosteroids for one month.

At a follow-up examination five months after surgery, her corrected visual acuity was 20/25 and her intraocular pressure was normal. The posterior capsule was clear centrally. There were some opacifi-cations of the capsule in the periphery after pupillary dilatation. The fundus was normal. Two months later the patient was hospitalized because of a sudden deterio­ration in visual acuity and profound hy­potony. Her corrected visual acuity was 20/80 and her intraocular pressure was 0 mm Hg. The anterior chamber was deep. Mild opacifications of the posterior capsule were detected in the pupillary area and some capsule wrinkles were present. The posterior pole of the fundus was normal. A 360-degree flat choroidal

detachment was found in the periphery. There was no wound leak and gonioscopy failed to disclose a cyclodialysis cleft. Topical treatment with corticosteroids and atropine for three days had no effect on the intraocular pressure.

On the third hospital day we noticed that the ciliary processes at the iridecto­my site were displaced anteriorly, almost bulging through the surgical coloboma. They seemed to be strongly connected to the posterior capsule and there were some traction lines from the ciliary proc­esses toward the center of the capsule. Because we suspected that the hypotony was produced by posterior capsule trac­tion on the ciliary body, we performed a posterior capsulotomy. The effect of this procedure was dramatic. Ten hours after surgery, the patient awoke with severe pain and was found to have corneal edema and an intraocular pressure in­creased to 50 mm Hg. The next day the intraocular pressure decreased to normal levels. The choroidal detachment disap­peared and the ciliary processes had moved away from the coloboma back into their normal position. At a follow-up visit six months later, the patient's corrected visual acuity was 20/25 and her intraocu­lar pressure normal.

Postoperative hypotony can occur after detachment of the ciliary body.1 The mechanism of the detachment is obscure, but Jaffe2 suggested that it might be caused by the surgeon grasping the iris close to its root during iridectomy. In our case the mechanism seemed to be differ­ent. The forward movement of the ciliary processes was related to a detachment of the ciliary body. This was caused by a traction of the pseudofibrotic prolifera­tion of the lenticular epithelial remnants on the most peripheral portion of the ciliary body. The response to capsul­otomy left no doubt that this hypothesis was correct. Once the capsule was open, the intraocular pressure became normal

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and the choroidal and ciliary body de­tachment disappeared. The acute in­crease in intraocular pressure a few hours after the capsulotomy was characteristic of sudden reattachment of the ciliary body and further supported our assump­tion that the hypotony was caused by posterior capsule traction.

With the continuing use of the extra-capsular technique in cataract surgery, the possibility of such a complication must be recognized.

REFERENCES 1. Chandler, P. A., and Maumenee, A. E.: A

major cause of hypotony. Am. J. Ophthalmol. 52:609, 1961.

2. Jaffe, N. S.: Cataract Surgery and Its Complica­tions. St. Louis, C. V. Mosby, 1981, p. 282.

PERMANENT IRIDOPLASTY

E M M E T T F. C A R P E L , M.D. , AND J. D A V I D B R O W N , M.D.

Hennepin County Medical Center, 701 Park Ave. South, Minneapolis, MN 55415 (Dr. Carpel)

Although there have been several re­cent reports dealing with modification of iris structure with the argon laser,1'3 per­manent alterations are difficult to achieve. We have obtained long-lasting results by administering laser burns through an Abraham lens.

Our patient, a 21-year-old woman, had headaches and eye pain, particularly in the evenings. Her intraocular pressure was variable, sometimes normal and on other occasions as high as 34 mm Hg in the right eye, and 42 mm Hg in the left eye. The central anterior chamber depths were normal, but the iris planes were flat and the angles were slit-like with only Schwalbe's line visible for 360 degrees in each eye. Prone provocative testing pro­

duced a 6-mm Hg increase in intraocular pressure in each eye. A laser peripheral iridotomy was performed in each eye. Because the patient's symptoms contin­ued, she underwent a mydriatic provoca­tive test in the left eye. An increase in intraocular pressure of 8 mm Hg was noted 15 minutes after instillation of one drop of 1% tropicamide. Gonioscopy dis­closed that the angle configurations had not changed since the iridotomy.

Because the patient could not tolerate even weak solutions of pilocarpine, we used laser iridoplasty to treat her plateau iris syndrome.4 Using the Abraham lens, we performed an iridoplasty for a 30- to 45-degree arc at the peripheral iris of each eye. Definite opening of the angles was achieved, allowing a view of the scierai spur (Figure). This has persisted for more than six months. The patient has

Figure (Carpel and Brown). Untreated angle on the left contrasts with the more open angle on the right. The peripheral iris on the right has had heavy but subiridotomy laser burns.