The association of iridoschisis and primary angle-closure glaucoma

Atypical presentation of bilateral iridoschisis with abnormal visibility of iris vessels: Role of anterior segment optical coherence tomography

PURPOSE

To describe clinical and anterior segment optical coherence tomography (AS-OCT) findings in a patient with bilateral iridoschisis and unilateral angle closure glaucoma (ACG) associated with abnormal visibility of iris vessels.

CASE PRESENTATION

A 67-year-old male patient with a history of red and painful left eye (LE) one year earlier, presented to our ophthalmology department for a routine examination.Ophthalmic examination of the right eye revealed narrow anterior chamber with sectorial iris atrophy associated to abnormal visibility of an iris vessel. Intraocular pressure (IOP) was 12 mmHg with normal optic disc appearance. LE anterior chamber was narrow with diffuse iris atrophy and abnormal vessels visibility. IOP was 28 mmHg with an important optic disc excavation. On gonioscopy, angle was narrow without neovessels nor synechiae. AS-OCT of both eyes revealed shallow angles, iris splitting with material release in the anterior chamber, while pigmented epithelium was preservedAnti-glaucoma eye drops were prescribed and peripheral laser iridotomy was performed in both eyes with decreased IOP at 14 mmHg in the LE.

CONCLUSION

Iridoschisis is a rare ocular condition characterized by a separation between the anterior and posterior layers of iris stroma with several clinical presentations, and may be associated with abnormal visibility of iris vessels in some cases. The diagnosis of iridoschisis may be challenging and AS-OCT can be a very useful tool to confirm the diagnosis in atypical presentations and to detect associated angle closure.

A case of iridoschisis with partial lens dislocation in both eyes

BACKGROUND

Iridoschisis is a rare condition that primarily affects individuals aged 60-70 years. The predominant characteristics of iridoschisis involve the tissue splitting and separation of the iris stromal layers, often resulting in two distinct layers and the presence of floating fibers in the anterior chamber. This article reports the case of a 48-year-old male with iridoschisis with partial lens dislocation in both eyes.

CASE PRESENTATION

Trauma is the leading factor in the development of iridoschisis. However, there is no documented case of ocular trauma in the patient's medical history. Visible white atrophic fibers were observed bilaterally in the anterior iris stroma of both eyes of the individual, accompanied by a small quantity of iris tissue within the anterior chamber. In this instance, the magnitude of the iridoschisis corresponded with the degree of lens dislocation. We were apprised that the patient had regularly used a cervical massager for a prolonged period of time, positioning it upon the ocular region. Frequent stimulation of both eyes with excessive force resulted in the development of iridoschisis and the partial dislocation of the lens.During the initial surgical procedure, phacoemulsification (Phaco) was carried out on the left eye without the placement of an intraocular lens (IOL). Following a two-month interval, we proceeded with the IOL suspension. Subsequently, the right eye underwent Phaco, accompanied by the implantation of an IOL. After closely monitoring the patient's progress for two months, it was evident that their vision had significantly improved, substantiating the success of the surgical interventions.

CONCLUSIONS

This finding posits that the recurrent friction applied to both eyes may induce iridoschisis and various ocular complications. In the event of ocular intricacies manifesting, expeditious medical intervention becomes imperative.

Iris clues in ACG

Primary angle closure glaucoma is a major cause of visual morbidity in Asia, which hosts 80% of the worldwide cases. In India, primary angle closure glaucoma (PACG) comprises almost 50% of adult glaucomas in hospital setting with its asymptomatic presentation predominating at 80%. Early diagnosis is critical to prevent the blinding trajectory of this disease, which is purported to cause twice as much blindness compared to open angle glaucoma. Traditional screening methods to identify PACG range from van Herick and flashlight test (relatively poor predictors) to gonioscopy (gold standard). Altered iris morphology are intrinsic to PACG, resulting in specific iris patterns. Iris appraisal could emerge as a method to screen underlying PACG. This would not only be specific, objective, but also easily performed at the peripheral level by a trained personnel and used in the era of tele-medicine for mass screening by AI softwares. This article seeks to detail these iris changes.

Iridoschisis: Spectrum of Presentation

PURPOSE:

The purpose of the study was to report a small case series of patients with iridoschisis seen at our hospital over a period of 5 years.

METHODS:

Retrospective review of all those files over the past 5 years whereby the diagnosis of iridoschisis/iris atrophy/iris fibrils in anterior chamber (AC) was made.

RESULTS:

In our case series, the average age at presentation was 49 years (range: 23–85 years). The pathology was bilateral in 57% of patients in our series. Our most common presentations were angle closure glaucoma and cataract. Younger individuals can also manifest iridoschisis.

CONCLUSION:

The iridoschisis can be an incidental finding, and gonioscopy should be performed in all the cases, as occludable or synechiael angle closure may be present in these cases.

Iridoschisis-A Systematic Review

Iridoschisis is a rare condition defined as a separation of the anterior iris stroma from the posterior stroma and muscle layers. In this paper, we review current data about the epidemiology, pathophysiology, clinical characteristics and differential diagnoses of this condition and discuss the specificity of surgical treatment of concomitant ocular diseases in iridoschisis patients. Iridoschisis may pose a challenge for both an ophthalmologist in an outpatient setting and an ophthalmic surgeon. Glaucoma, primarily angle-closure glaucoma, is the most often described condition concomitant to iridoschisis. Other ocular abnormalities found relatively often in iridoschisis patients include cataract, lens subluxation and corneal abnormalities. Special attention has been paid to potential complications of cataract surgery and prevention thereof. Beside addressing the practical aspects, we point to discrepancies and suggest topics for further investigation.

Iridoschisis: visual outcome in treated versus untreated eye

A 67-year-old man was referred for iris color change. He was noted to have narrow angles with atrophic iris appearance and visually significant cataracts. The iris findings were consistent with iridoschisis. The patient was recommended to have cataract surgery. Unfortunately, he was lost to follow-up. One year later, he presented with chronic angle closure glaucoma on the right eye with very high pressure and very poor remaining vision. Left-eye vision was also compromised with cataract. Despite the presence of small pupil, abnormal iris stroma, and dense cataract, the patient underwent successful cataract surgery and achieved 20/20 vision post-operatively. Iridoschisis can cause substantial ocular morbidity if not treated timely.

Massive iridoschisis after penetrating keratoplasty successfully managed with nd:Yag punctures: A case report

BACKGROUND

To describe the successful management of a massive iridoschisis after penetrating keratoplasty for keratoconus, using the nd:YAG punctures.

CASE PRESENTATION

A 73-year-old male patient has undergone four penetrating keratoplasties for keratoconus. Nine months after the last surgery, patient presented with massive iridoschisis involving the visual axis. Patient was successfully treated with nd:YAG laser iridopunctures.

CONCLUSION

Massive iridoschisis could be a potential complication of keratoconus, especially after penetrating keratoplasty. This condition can be potentially treated with nd:YAG iridopunctures.

Goniosynechialysis combined with cataract extraction for iridoschisis: A case report

RATIONALE

Iridoschisis is a rare eye disease. In this case report, we described the examination and diagnosis of a case of iridoschisis accompanied by secondary glaucoma. We also observed the effects of treating the patient with a combination of goniosynechialysis and cataract removal.

PATIENT CONCERN

A 67-year-old female patient presented with decreased vision in both eyes. An eye examination indicated that visual acuities (VAs) were 20/100 and light perception in the right and left eyes, respectively. Both eyes exhibited shallow anterior chambers and narrow angles. The lower portion of the iris was loosened, and cable-like tissue was visible. The intraocular pressures in the right and left eyes were 22 mmHg and 58 mmHg, respectively. At the time of presentation, no medication was being used.

DIAGNOSES

The patient was diagnosed with iridoschisis [oculus sinister (OU), indicates left eye], secondary glaucoma (OU), senile cataract (OU), and pterygium (oculus uterque, indicates both eyes).

INTERVENTION

After relevant examinations were conducted, goniosynechialysis and phacoemulsification with intraocular lens implantation were performed on the right eye under local anesthesia.

OUTCOMES

Two days after surgery, the right eye had VA of 20/40 and a transparent cornea. The anterior chamber was deeper, and intraocular pressure had decreased to 16 mmHg. Three months after surgery, the patient exhibited improved VA in the right eye and a lower IOP of 11 mmHg.

LESSONS

Relative to other approaches, goniosynechialysis combined with cataract removal is a better treatment option for iridoschisis complicated with closed-angle glaucoma triggered by peripheral anterior synechiae.

Iridoschisis: a case report and literature review

Background

Iridoschisis is a rare condition that is characterized by the separation of the iris stroma into layers, with portions of the anterior layer floating freely in the aqueous humour. Here, we report three cases of iridoschisis that were complicated by either a cataract or glaucoma. Based on these cases, we speculate that the scope of iridoschisis has a rare association with intraocular pressure and the loss of corneal endothelial cells after surgery, which is mainly due to the surgery and not iridocorneal mechanical contact.

Case presentation

We report three cases of iridoschisis, two of which were complicated by cataracts and the third by glaucoma. Patient 1 was a 69-year-old man with bilateral iridoschisis complicated by a cataract but not glaucoma, even though the entire anterior layer of the iris stroma in the right eye presented as white atrophic strands. To prevent the detached iris fibrils from invading the phacoemulsification tip and the irrigation/aspiration hand piece port, the separated iris stroma that was floating freely in the aqueous humour was cut with scissors immediately before the cataract extraction. Patient 2 was an 87-year-old woman with iridoschisis complicated by a cataract in the right eye. We successfully performed cataract surgery on the right eye without a pupillary device. Patient 3 was a 66-year-old man who presented with increased intraocular pressure with bilateral iridoschisis. He was discharged and prescribed with a combination of four glaucoma drugs.

Conclusions

Patients with iridoschisis should have continuous follow-up because complications may occur, and extra care from ophthalmologists is required.

Iridoschisis and keratoconus in a patient with severe allergic eye disease and compulsive eye rubbing: a case report

BACKGROUND

Iridoschisis is a rare disorder characterized by splitting of the anterior and posterior iris stroma, resulting in disintegrated iris fibrils which float freely in the anterior chamber. We report an exceptional case of bilateral iridoschisis occurring in conjunction with keratoconus and severe allergic eye disease.

CASE PRESENTATION

A 24-year-old white man had had periocular contact dermatitis and allergic eye disease from the age of 3 years. He was allergic to grass, animal hair, and pollen and worked grooming horses. He compulsively rubbed his eyes. There was no history of previous blunt trauma to either eye. There were signs of bilateral iridoschisis and keratoconus with allergic conjunctivitis, all of which were more severe in his right eye. An open drainage angle was identified bilaterally on gonioscopy, excluding primary angle closure. There was no evidence of glaucoma in either eye.

CONCLUSIONS

There are two previous cases reporting the combination of iridoschisis and keratoconus, but no clear common etiology has been identified. In this case there was no evidence of angle closure but there were signs of allergic conjunctivitis. This amalgamation of signs might be explained on the basis of habitual eye rubbing. Treating the allergic eye disease has attenuated this behavior.

Juvenile iridoschisis and incomplete plateau iris configuration

INTRODUCTION

Iridoschisis is a rare condition in which there is localized cleavage of the iris stroma into 2 layers. It can be associated with plateau iris and more often with either angle closure or open-angle glaucoma. It usually presents in later life as a bilateral progressive condition, however, in this article we present a young adult with bilateral iridoschisis and incomplete plateau iris configuration.

CASE PRESENTATION

We report the case of a 22-year-old male with bilateral sensorineural hearing loss who presented to clinic for general ophthalmology evaluation. He had no prior ocular history. Examination findings revealed bilateral iridoschisis with incomplete plateau iris configuration. His ocular examination was otherwise unremarkable except for bilateral retinal pigment epithelium mottling. His work-up for glaucoma including optic disc evaluation, visual field testing, and imaging was all within normal limits.

CONCLUSIONS

This case is unusual in its presentation of a young patient with bilateral iridoschisis and incomplete plateau iris configuration. Iridoschisis is more commonly a senile process and the presence of iridoschisis in a young adult prompts a review of congenital causes and associations. Although this patient had no evidence of glaucoma at this time, given the associated risk, it is important that he continue to have regular follow-up at this time.

Iridoschisis associated with nanophthalmos and bullous keratopathy

Iridoschisis is a rare condition in which the iris stroma splits into anterior and posterior layers. Iridoschisis is associated with anterior segment abnormalities including keratoconus, lens subluxation and angle-closure glaucoma. We describe the first case in which iridoschisis has occurred in association with nanophthalmos. We also report the rare complication of irido-corneal touch and subsequent corneal decompensation. Nanophthalmos and irido-corneal touch are sight-threatening associations of iridoschisis and should be excluded in all patients with this rare condition.

Iridoschisis: case report and review of the literature

Iridoschisis is a rare condition that consists of the separation of the anterior mesodermic layer of the iris. In more than two-thirds of cases it is associated with glaucoma. We report the case of an 80-year-old patient who had bilateral iridoschisis and presented with acute angle-closure glaucoma. The patient was free from a history of ocular trauma or of heritable ocular disease. Chronic open-angle glaucoma, as well as intermittent angle-closure glaucoma, should be excluded in all patients with iridoschisis, and regular follow-up should be established upon diagnosis of the entity.

A case of cataract surgery without pupillary device in the eye with iridoschisis

Purpose

To introduce a case of iridoschisis patient who underwent cataract surgery successfully without pupil device.

Methods

A 64-year-old female who showed iridoschisis of her both eyes underwent cataract operation at her right eye without a pupillary device. The preoperative and postoperative ophthalmologic examinations including visual acuity, intraocular pressure, reaction of anterior chamber, and degree of damage on iris was evaluated respectively.

Results

Cataract surgery was performed under topical anesthesia through a clear corneal incision. Iris fibrils were held in place by ophthalmic viscosurgical device (OVD, sodium hyaluronate 3%-sodium chondroitin sulfate 4%, Viscoat®) that was injected into the anterior chamber. A small capsulorrhexis was made and the nucleus was delivered with low-power phacoemulsification, most of which was performed under the anterior capsule. The iris came into contact with the OVDs only and received no mechanical trauma. There were no intraoperative complications such as tear of the iris, hyphema, loss of mydriasis, or rupture of the posterior lens capsule. The edema of corneal stroma and inflammation of anterior chamber was shown at immediate-postoperative period, but completely subsided 2 weeks later. The visual acuity showed improvement from 20/400 to 20/30.

Conclusions

In iridoschisis patients, there is a risk of aspiration of iris fibers during cataract surgery. With adequate use of OVD and careful modulation of surgical devices, cataract surgery was successfully performed without using extra pupil-supporting device.

Avoiding iris trauma from phacoemulsification in eyes with iridoschisis

Iridoschisis is a rare condition frequently associated with age-related cataract. Phacoemulsification can be difficult to perform in these eyes, as the detached iris fibrils that are typically present free float in the anterior chamber and are attracted to the phaco tip and the irrigation/aspiration handpiece port. We describe a technique for performing phacoemulsification in eyes with iridoschisis. In this technique, iris fibrils are held in place by 2 ophthalmic viscosurgical devices (OVDs) that are injected into the inferior portion of the anterior chamber. An elliptical capsulorhexis is made and limited to the superior half of the pupil for additional stability of the anterior chamber during surgery. The nucleus is chopped with a phaco chopper and a bent-tip, 22-gauge needle. Most of the phacoemulsification is performed under the anterior capsule. The iris comes into contact with the OVDs only and has no mechanical trauma.

Iridoschisis and bilateral lens subluxation associated with periocular eczema

We present a 53-year-old man with bilateral lens subluxation, unilateral iridoschisis, and a long-standing history of periocular eczema. Although a case of unilateral lens subluxation and ipsilateral iridoschisis has been described recently, the pathogenesis of this simultaneous occurrence remains unclear. Our case raises questions about the relationship among these clinical observations and suggests that these findings may exist as part of an unrecognized oculodermal syndrome.

Iridectomy of the anterior iris stroma using the vitreocutter during phacoemulsification in patients with iridoschisis

We present a technique to manage iridoschisis. This technique for anterior iridectomy of the affected iris fibers avoids intraoperative obstruction of the phaco tip and prevents postoperative complications such as corneal decompensation and glaucoma. Before the capsulorhexis is created, a vitreocutter is inserted in the anterior chamber and used to cut the iris strands at the site of the iridoschisis, making an anterior sectorial stromal iridectomy and preserving the iris pigment epithelium. Phacoemulsification is then performed. After the pupil is constricted with carbacol, remnants of the loose anterior iris fibers are excised with the vitreocutter and the scleral incision is sutured.

Iridoschisis associated with lens subluxation

The etiopathogenesis of iridoschisis is unclear, although age-related degeneration and angle-closure glaucoma are its most common associations. We report the case of a 50-year-old man with lens subluxation (familial) in 1 eye and ipsilateral iridoschisis. The inferotemporal edge of the lens was directed anteriorly, pushing the iris forward; this led to iridoschisis and shallowing of the anterior chamber. The patient had bilateral angle-closure glaucoma. A subluxated lens rubbing against the iris may be a mechanical precipitating factor in the development of iridoschisis.

Iridoschisis

Iridoschisis is a rare condition in which a localised area of iris stroma is cleaved in two with the anterior atrophic portion disintegrating into fibrils. The most common presentation of iridoschisis is as an age-related iris atrophy in association with glaucoma. The association includes angle-closure glaucoma, angle-recession glaucoma and open-angle glaucoma. A finding of iridoschisis is a warning to the clinician to assess the patient for pre-existing glaucoma and to monitor for glaucomatous changes as it is unclear if iridoschisis is a cause or an effect of raised intraocular pressure (IOP).

Iridoschisis: high frequency ultrasound imaging. Evidence for a genetic defect?

AIMS

To elucidate changes in the anatomy of the anterior chamber associated with iridoschisis, a rare form of iris atrophy, and their potential contribution to angle closure glaucoma.

METHODS

Both eyes of a 71-year-old woman with bilateral iridoschisis and fibrous dysplasia and her asymptomatic 50-year-old daughter were scanned with a very high frequency (50 MHz) ultrasound system.

RESULTS

The symptomatic patient exhibited diffuse changes in the iris stoma with an intact posterior iris pigmented layer in both eyes. These changes were clinically compatible with the lack of iris transillumination defects. Additionally, iris bowing with a resultant narrowing of the angle occurred. The asymptomatic daughter showed discrete, but less severe iris stromal changes.

CONCLUSION

This is the first detailed study of high frequency ultrasonic imaging of the iris in iridoschisis. The observed structural changes suggest angle narrowing by forward bowing of the anterior iris stroma may be a mechanism of IOP elevation in this condition. The ultrasonic detection of iris changes in the asymptomatic daughter of the symptomatic patient and the association of iridoschisis with fibrous dysplasia suggest a possible genetic component in the pathogenesis of this condition.