CASE PRESENTATION
An 89-year-old woman is referred by a retina colleague. The patient developed traumatic mydriasis, IOL dislocation, vitreous hemorrhage, and ocular hypertension after an exercise band snapped and hit her right eye. She subsequently underwent a vitrectomy.
The patient presents with an aphakic right eye and symptomatic glare (Figure). Her BCVA is 20/150+ OD with a refraction of +11.50 +0.75 x 150º. The IOP in the right eye is currently controlled on a therapeutic regimen of latanoprost, a fixed combination of dorzolamide hydrochloride and timolol maleate, and brimonidine. An age-related reduction in her hand-eye coordination, however, makes it difficult for her to instill the topical drops.

Figure. Traumatic mydriasis, aphakia, and previous scleral tunnel superiorly.
How would you proceed?
—Case prepared by Cristos Ifantides, MD, MBA

ROBERT FISH, MD
Assuming the patient is uninterested in nonsurgical options and is a good surgical candidate, her reduced visual acuity would be investigated to determine the eye’s visual potential. Her bilateral pachymetry readings and color vision would be assessed, and reverse testing for a relative afferent pupillary defect would be performed to rule out corneal edema, traumatic optic neuropathy, and advanced glaucoma. Traumatic macular pathology such as commotio retinae, macular hole, and choroidal rupture would also be excluded.
The vitreous hemorrhage in a unicameral eye makes me suspect angle recession, so gonioscopy is indicated. If there is no angle recession, selective laser trabeculoplasty and/or angle-based MIGS such as goniotomy could reduce the patient’s topical medication burden. Conversely, if angle recession is present, she may ultimately require the placement of a tube shunt, preferably in the sulcus or pars plana in this vitrectomized eye.
Once the glaucoma treatment plan has been formulated, scleral fixation of an IOL with a simultaneous pupilloplasty would be planned. The patient’s previous records would be consulted for the prior IOL power and biometry measurements. The Yamane technique is my preference for flanged intrascleral haptic fixation (ISHF).1 It is typically performed with one of the following two lenses: the Tecnis (model AR40, Johnson & Johnson Vision) or the CT Lucia (model 602, Carl Zeiss Meditec). Each has its advantages. The polyvinylidene fluoride haptics of the CT Lucia are easier to manipulate intraoperatively.
No iris tissue loss is evident in the eye. In situations like this, traumatic mydriasis is usually the result of trauma to the sphincter muscle rather than fibrosis or synechiae. The tissue should therefore be relatively amenable to manipulation. Intraocular forceps (MicroSurgical Technologies) would be used to grasp the iris margin and gently pull the tissue toward the center. A single-pass four-throw pupilloplasty technique would be an easy and effective approach, and it would likely create a functional pupil. Iris cerclage would be slightly more challenging but would create a rounder pupil. When executing the latter technique, I use a 10-0 polypropylene suture on a CIF-4 needle (Prolene, Ethicon) and aim for a fixed pupil size of around 3.5 mm.

BEERAN MEGHPARA, MD
There are three main considerations in this case: the patient’s aphakia, traumatic mydriasis, and elevated IOP.
Although not perfect, her BCVA represents a meaningful improvement over her aphakic UCVA. Given her age and difficulty administering eye drops, contact lens wear is not a feasible option. I would therefore recommend the implantation of a secondary IOL. To minimize disruption of the conjunctiva (in the event the patient requires future glaucoma surgery), flanged ISHF of the IOL using the Yamane technique would be my preference.
Surgical repair of the traumatic mydriasis would be performed to address the glare she is experiencing. Iris cerclage would be my preferred approach because it could create a round pupil that could be adjusted to the desired 3- to 4-mm diameter. This technique is challenging, however, so multiple single-pass four-throw pupilloplasties would be a reasonable alternative.
Gonioscopy would be performed to check the eye for angle recession and chronic angle closure. An assessment of the optic nerve would also be conducted. I would consider performing a goniotomy to bypass the damaged trabecular meshwork associated with angle recession. Combining this procedure with the goniosynechialysis effect of the pupillary cerclage could help address chronic angle closure. If severe optic nerve cupping is detected and the IOP is not sufficiently controlled, the patient would be referred to a glaucoma specialist postoperatively for potential filtration or tube shunt surgery.

WHAT I DID: CRISTOS IFANTIDES MD, MBA
Concern about the patient’s possible future need for glaucoma surgery led me to use the Yamane technique for the ISHF of a CT Lucia lens to minimize disruption to the conjunctiva (watch the surgery below).
When performing ISHF after a vitrectomy (especially if large incisions were made to remove the IOL), I carefully avoid prior cicatricial areas on the ocular surface that could jeopardize the scleral tunnel made with needles. Any modifications I make to the Yamane technique depend on the status of the eye during surgery. Recently, I have tended to dock the leading haptic into a 30-gauge thin-walled needle while the IOL is being injected into the eye and then externalize the haptic and create a bulb before turning my attention to the trailing haptic. When performing these steps, I have found it important to push the leading haptic with the bulb back into the sclera to facilitate docking of the trailing haptic. In my experience, if the leading haptic is overly externalized, poor positioning of the IOL makes docking the trailing haptic into the 30-gauge needle difficult.
After ISHF was complete and the IOL was well centered, 360º of the iris was pulled away from the angle with serrated intraocular forceps (MicroSurgical Technology). This helped me identify the best tissue to work with to address the traumatic mydriasis. As Drs. Fish and Meghpara note, pupillary cerclage typically works well in situations like this one, but I have found placing multiple single-pass four-throw sutures to be easier, faster, and equally efficacious, especially in unicameral eyes. Two single-pass four-throw sutures were therefore placed with a targeted pupillary diameter of 4 mm to facilitate future retinal examinations.
Because preoperative gonioscopy had revealed traumatic mydriasis and a sealed angle, a goniosynechialysis and goniotomy were then performed.
An autorefraction showed an improvement from a spherical equivalent of +11.50 D preoperatively to +0.50 D on postoperative day 1. The unmedicated IOP was in the single digits. The patient’s UCVA was counting fingers at 6 inches, and she reported a subjective improvement. Mild corneal edema was evident at the slit lamp. The posterior pole appeared to be flat during a limited examination with a +90.00 D lens.
One week after surgery, the patient’s UCVA was hand motions, and the IOP remained in the single digits. Fundus photography and OCT imaging indicated that a macula-off retinal detachment (RD) had occurred. The patient was urgently referred to her retina specialist for evaluation and management and subsequently underwent RD repair.
The rate of complications is unfortunately higher in severely traumatized eyes—even when everything goes well in the OR. Potential postoperative complications include vitreous hemorrhage, choroidal hemorrhage, iris chafe or capture, glaucoma, RD, cystoid macular edema, and epiretinal membrane.2,3 This case highlights the importance of properly educating patients and emphasizing the guarded prognosis before surgery. Maintaining close follow-up with retina colleagues can be critical even when the anterior and middle segment surgeries are uneventful.
1. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124(8):1136-1142.
2. Shelke K, Rishi E, Rishi P. Surgical outcomes and complications of sutureless needle-guided intrascleral intraocular lens fixation combined with vitrectomy. Indian J Ophthalmol. 2021;69(9):2317-2320.
3. Sahin Vural G, Guven YZ, Karahan E, Zengin MO. Long term outcomes of Yamane technique in various indications. Eur J Ophthalmol. 2023;33(6):2210-2216.