CORRESPONDENCE

Pupillary block glaucoma following descemetstripping automated endothelial keratoplastyrelated to intraoperative floppy-iris syndrome

We present a case in which floppy iris secondary totamsulosin led to intraoperative and postoperative compli-cations in descemet stripping automated endothelial kera-toplasty (DSAEK). A 62-year-old phakic male with Fuchs’endothelial dystrophy underwent DSAEK. Intraopera-tively, the peripheral iris was extremely lax and had amarked tendency to prolapse. At the end of the procedure,the size of the air bubble encompassing the graft host junc-tion was reduced to 75%, and tobramycin, dexametha-sone, and cyclopentolate drops were instilled.Several hours postoperatively, the patient developed sig-

nificant ocular pain and vomiting. His visual acuity wascounting fingers, his pupil was mid-dilated and fixed, andhis intraocular pressure (IOP) was 50 mm Hg. The airbubble in the anterior chamber completely blocked thepupil with peripheral iris bowed 360u. Corneal haze pre-cluded YAG iridectomy. The IOP was lowered with ananterior-chamber tap that reduced the size of the gas bubbleto 70% and a massage of the peripheral iris out of the blockposition. The patient received brimonidine, cyclopentalate,and oral acetazolamide. The IOP the following day was10 mmHg. Subsequent medications were gatifloxacin, dex-amethasone 0.1%, and homatropine 5% QID. Homatro-pine was discontinued 6 days postoperatively when the airbubble disappeared. Two months postoperatively the IOPwas normal and best-corrected visual acuity was 20/2521.Our patient had a classic case of intraoperative floppy-

iris syndrome (IFIS), described as a flaccid iris dilatormuscle, a tendency to prolapse, and progressive pupillaryconstriction.1–2 Although pupillary block glaucoma inDSAEK has been reported,3 the association with IFIS hasnot been described. In our patient, poor dilation and pro-gressive pupil constriction resulted in pupillary block des-pite pharmacologic dilation. Early intervention broke theair-bubble ball-valve effect on the constricted pupil.It is possible that the air bubble stimulated the pupillary

constrictor muscle. Under the influence of tamsulosin, thepupil sphincter muscle had little counterbalance from theaffected dilator muscle which lead to a floppy peripheryand early miosis. We suspect that the air bubble may haveprovided a low-grade irritant accentuating the miosis.

The pre- and postoperative use of nonsteroidal anti-inflammatory drugs may stabilize the contact cells leadingto less inflammatory mediator release and thus less miosisstimulus. Preoperatively, patients on tamsulosin should beconsidered for an inferior laser peripheral iridectomy. Intra-operatively, donor insertion may be facilitated with a glideor suture-drag technique.4

In patients with cataracts, a triple procedure may be ben-eficial to minimize the surgical trauma that can occur withmultiple surgeries and to increase the volume of the anteriorsegment to reduce the risk of pupillary block. Patients should,however, be warned of the lessened accuracy of intraocularlens power determination. In our case, surgery was limited toDSAEK because the patient had clear lenses. In such cases, itis prudent to leave the pupil undisturbed until the graft isadherent. Dilating the pupil towards the end of the caseprovides protection to the lens.As in cataract surgery, IFIS can complicate a DSAEK.

The surgeon shouldmaintain a high index of suspicion,1–2,5

and the patient should be aware of the higher risk forcomplications.

Julia Baryla & Alexander C. TokarewiczIvey Eye Institute, University of Western Ontario, London, Ont.

Correspondence to:Julia Baryla, MD;: juliabaryla@gmail.com

REFERENCES

1. Chang DF, Campbell JR. Intraoperative floppy-iris syndromeassociated with tamsulosin. J Cataract Refract Surg. 2005;31:664–73.

2. Chang DF, Braga-Mele R, Mamalis N, et al. ASCRS White Paper:Clinical review of intraoperative floppy-iris syndrome. J CataractRefract Surg. 2008;34:2153–62.

3. Lee JS, Desai NR, Schmidt GW, Jun AS, et al. Secondary angle closurecaused by air migrating behind the pupil in Descemet StrippingEndothelial Keratoplasty. Cornea. 2009;28:652–6.

4. Bradley JC,McCartneyDL.Descemet’s stripping automated endothe-lial keratoplasty in intraoperative floppy-iris syndrome: Suture-dragtechnique. J Cataract Refract Surg. 2007;33:1149–50.

5. Chang DF, Osher RH, Wang L, Koch DD. Prospective MulticenterEvaluation of Cataract Surgery in Patients Taking tamsulosin(Flomax). Ophthalmology. 2007;114:957–64.

Can J Ophthalmol 2011;46:202

doi:10.3129/i10-119

202 CAN J OPHTHALMOL—VOL. 46, NO. 2, APRIL 2011