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How to manage extreme deepening of the anterior chamber during phacoemulsification in myopic and vitrectomized eyes?

Extreme deepening of the anterior chamber during phacoemulsification in myopic and vitrectomized eyes is due to intraoperative reverse pupillary block between the iris diaphragm and anterior lens capsule.

This syndrome is known as lens-iris diaphragm retropulsion syndrome (LIDRS) and is characterized by significant backward displacement and bowing of the iris, marked deepening of the anterior chamber and pupil dilation.1

LIDRS occurs more often than recognized during phacoemulsification and can result in difficult and prolonged surgery as well significant ocular discomfort in patients operated under topical anaesthesia². Conditions that favor marked posterior displacement of the iris and occurrence of this syndrome are young age, high myopia, and previous vitrectomy.

At early stages LIDRS can be managed by lowering the infusion bottle to reduce the pressure in the anterior chamber and may be adding a second infusion line to allow sufficient inflow at a lower pressure. Placing a single iris retractor can also circumvent the occurrence of this problem as it will prevent contact between the iris and lens capsule.³ An established reverse pupillary block, can be broken by separating the iris from the anterior capsule’s rim with the second instrument.³ In our hands, this maneuver is very effective but often needs to be repeated during the course of surgery as LIDRS will recur each time surgeon initiates the infusion anteriorly. Moreover, surgeon should keep in mind that pupil size will decrease as the iris is stretched away from the anterior capsule.

In summary, knowledge of LIDRS can help surgeons resolve the problem of extreme deepening of the anterior chamber during phacoemulsification in myopic and vitrectomized eyes.

1. Zauberman H. Extreme deepening of the anterior chamber during phacoemulsification. Ophthalmic Surg. 1992;23:555-556.

2. Wilbrandt HR, Wilbrandt TH. Pathogenesis and management of the lens-iris diaphragm retropulsion syndrome during phacoemulsification. J Cataract Refract Surg. 1994;20:48-53.

3. Nahra Saad D, Castilla Cespedes M, Martinez Palmer A, Pazos Lopez M Phacoemulsification and lens-iris diaphragm retropulsion syndrome. Ophthalmic Surg Lasers Imaging. 2005 Nov-Dec;36(6):512-3.

 

Samiksha Fouzdar-Jain, MBBS,DNB ,FRCS

Ahmed Sallam, PhD, FRCS, FRCOphth

 

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