Occlusio Pupillae: A Duet of Darkness Where the Patient Sees Naught, and the Doctor Discerns Not

Abstract

A 71-year-old, one-eyed female patient presented with a loss of vision in the right eye due to trauma 20 years ago and a progressive diminution of vision in the left eye over the past six years. An ambiguous history of some surgery performed on the left eye was elicited, with no available records, adding an element of uncertainty to this case. Visual acuity (VA) was noted as no light perception (No PL) in the right eye and light perception with accurate projection of rays (PL+, PR accurate) in the left eye. Anterior segment slit-lamp evaluation of the right eye showed a shrunken globe with low intraocular pressure (IOP). The left eye exhibited signs of chronic uveitis with occlusio pupillae, non-visualization of the lens, and a doubtful conjunctival bleb with scleral thinning superior to the limbus. B-scan evaluation was suggestive of phthisis in the right eye and an equivocal lens shadow in the left eye. A yttrium aluminum garnet (YAG) pupillary membranotomy was planned for the left eye under steroid cover and was cautiously attempted, successfully detaching the occlusio membrane and revealing an underlying complicated cataract beneath it. Post-laser, medical management included topical anti-glaucoma and steroid medications, along with systemic steroids. The VA improved from PL+, PR accurate to 3/60 (improving to 6/60 with a Retinal Acuity Meter). After stabilization of the uveitis over the next few weeks and under a steroid cover, a temporal clear-corneal phacoemulsification was cautiously performed with intra-operative management of the small pupil, and a hydrophobic lens was implanted. At one month post-surgery, the patient's best-corrected visual acuity had improved to 6/12 for distance and N6 for near. This report highlights a compelling instance wherein the neodymium:Yttrium-aluminum-garnet (Nd:YAG) laser was efficaciously employed for a lesser-known application in resolving a diagnostic dilemma and for instituting an interim treatment strategy in a challenging case involving a one-eyed patient prior to planning a definitive surgery. This case emphasizes the importance of thinking out of the box, ensuring comprehensive preoperative and careful intra-operative precautions in the management of patients diagnosed with complex ocular inflammatory conditions, so as to optimize visual outcomes, eventually resulting in achieving a gratifying reduction of visual disability and improvement of quality of life.

Keywords: complicated cataract; glaucoma; neodymium:yttrium-aluminum-garnet (nd:yag) laser applications; occlusio pupillae; one-eyed patient; phacoemulsification; phthisical eye; pseudo-bleb; uveitis; yag pupillary membranotomy.

Figure 1. Phthisical right eye (slit lamp examination).

Figure 2. B-scan RE (phthisical shrunken eye).

Disorganized globe is seen. The vitreous (green arrow) is full of dot echoes due to a possible old vitreous hemorrhage. Intrascleral calcification is seen (yellow arrow). The lens complex echo is not clearly discernible (red arrow). RE: Right Eye; B-scan: Brightness Scan.

Figure 3. Bleb-like elevation superior to the limbus.

The dotted outline corresponds to the bleb-like elevation superior to the limbus. The black arrow points to the pigmentary line demarcating the bleb margin. The red arrow points to the pigmented uveal tissue seen through an area of localized scleral thinning. Differential Diagnoses: (1) Secondary to a possible prior Mitomycin-C application, or (2) An early or evolving intercalary staphyloma. (However, there was a doubtful history of surgery and no definitive history of trauma in the past).

Figure 4. Seidel's test negative.

Some pooling of fluorescein dye is observed along the superior and inferior margins of the bleb.

Figure 5. Anterior segment left eye.

Broad anterior synechiae with irido-corneal adhesion from 7 to 10 o'clock nasally (broken red line demarcating the extent of adhesion). Occlusio pupillae (green arrows).

Figure 6. LE: Nasal slit beam showing irido-corneal adhesion.

Iridocorneal adhesion is seen as an irregularity on the posterior corneal surface (white arrows). LE: Left eye.

Figure 7. LE: Slit beam showing occlusio pupillae.

Pupillary membrane (red arrow) with early iris bombe (white small arrows). LE: Left eye.

Figure 8. LE: Gonioscopy findings.

No trabeculectomy stoma seen superiorly (panel A). Anterior synechiae and adhesions seen nasally (panel D: white arrow). LE: Left eye.

Figure 9. B-scan: LE.

The optic nerve (ON) shadow is normal. The vitreous shows a few reflective echoes. The globe is organized. The capsular bag is seen, but a definitive IOL versus lens echo is not discerned (yellow arrow). LE: Left eye; IOL: Intraocular lens.

Figure 10. LE: AS SS-OCT: on presentation.

A slightly bulging pupillary membrane (red curved double arrow) is seen adherent to the pupil centrally. The iris and anterior lens capsule (LC) cannot be optically differentiated anteriorly in the region around the membrane (blue double arrow). Posterior structures are not visible. LE: Left eye; AS: Anterior segment; SS-OCT: Swept-source optical coherence tomography.

Figure 11. LE: post-YAG membranotomy.

The pupillary membrane has been released from the pupil along 360 degrees of its margin. An iris shadow (red arrow) is seen on the cataractous lens (white arrow). A central shriveled tag of the pupillary membrane is visible on the anterior lens capsule (green arrow). LE: Left eye; YAG: Yttrium Aluminum Garnet.

Figure 12. LE: slit beam view post YAG membranotomy.

A cataractous lens (white arrow) is seen with remnants of the pupillary membrane (green arrow). LE: Left eye; YAG: Yttrium Aluminum Garnet.

Figure 13. LE: anterior segment SS-OCT after YAG membranotomy.

A tag of the membrane is seen attached (red arrow) to the thickened anterior lens capsule (blue arrow). The pupil appears larger, and lens details are more clearly seen than earlier (Figure 10). The dense nucleus is separated from the anterior and posterior cortex (Cx) by a clear, lucent zone (white arrows). The beam travels to the retina (yellow arrow). LE: Left eye; SS-OCT: Swept-Source Optical Coherence Tomography; YAG: Yttrium Aluminum Garnet.

Figure 14. LE: post-cataract surgery: pseudophakia, slightly irregular pupil.

LE: Left eye.

Figure 15. LE: post cataract surgery: pseudophakia with red glow.

LE: Left eye.

Figure 16. LE: Fundus (post-cataract surgery).

A CD ratio of 0.8 is observed (yellow arrow). The cup appears deep. The neuro-retinal rim is pale (red arrow) with thinning of the superior and inferior rims (green arrows). Some retinal exudates are visible near the arcades (small white arrows). LE: Left eye; CD ratio: Cup-to-disc ratio.