Prolaps iris emedicine

Background
The iris is a thin, colored diaphragm that is situated anterior to the lens. Although the root of the iris is attached to the ciliary body, the rest of the iris is unsupported. In the event of a corneal wound, the iris tends to prolapse out. Iris prolapse occurs when the iris tissue is observed outside of the wound; iris incarceration occurs when the iris tissue reaches the wound without prolapsing outside the eye. Iris prolapse may also occur as part of a condition called intraoperative floppy iris syndrome (I I!" during cataract surgery or trabeculectomy. This condition is associated with the use of several systemic alpha #$ adrenergic antagonists, such as tamsulosin ( loma%". Intraoperative floppy iris syndrome is characteri&ed by poor pupillary dilation, progressive pupillary constriction, and intraoperative iris billowing. '#(

)athophysiology
Iris prolapse can occur when the cornea is perforated due to any cause. In #**+, using flow mechanics and the Bernoulli principle, Allan provided a theoretical e%planation of iris prolapse.',( -ith a corneal perforation, the a.ueous humor rapidly escapes, and a relative vacuum is created in front of the iris, thus leading to iris prolapse.

/pidemiology
Frequency
United States The e%act incidence of iris prolapse in the 0nited !tates is unknown, but the overall estimated rate of all eye in1uries ranges from 2.,$#3 per #444 population. /ye in1ury rates are highest among individuals in their ,4s, males, and whites. International The incidence rate worldwide is unknown.

Mortality/Morbidity
Iris prolapse is a serious condition and, if left untreated, can result in infection and loss of the eye. If the prolapsed iris is e%posed (eg, corneal laceration", immediate surgical intervention is needed because infection can spread through the iris and into the eye. If the prolapsed iris is covered by the overlying con1unctiva (eg, surgical wound", immediate surgical intervention is usually not needed.

Race
5o racial predilection e%ists.

Sex
Iris prolapse is probably more common in young men than in young women.

Age
Age is not a significant factor for iris prolapse.

6istory
The iris is a sensitive tissue in the eye. At the time of an iris prolapse, patients often e%perience pain. )atients with a perforated corneal ulcer fre.uently provide a history of severe pain that has since subsided. The iris can prolapse after surgery (eg, cataract, corneal transplant", following trauma (eg, corneal laceration, scleral laceration", through a perforated corneal ulcer, or through a corneal melt associated with rheumatoid arthritis.

-ith improvements in microsurgical techni.ues, iris prolapse after surgery is uncommon. Iris prolapse with a perforated corneal ulcer is rare. In the author7s e%perience, the most common cause of iris prolapse is following trauma; however, the e%act incidence is not known.

)hysical
In peripheral iris prolapse, the iris appears as a knuckle of colored tissue, resulting in a partial peripheral synechia. -hen the prolapse is central, the entire pupillary margin may prolapse, resulting in a total anterior synechia. In patients with a perforated cornea, the prolapsed iris is e%posed. 8epending on the duration of prolapse, the appearance of the iris may vary. In cases of recent prolapse, the iris appears viable. -ith time, the iris appears dry and nonviable. In patients who have undergone corneal transplant surgery or cataract surgery with a clear corneal incision, the appearance of the iris is the same as in a perforated cornea. -hen the iris prolapses through a scleral wound, it appears as a colored mass beneath the overlying con1unctiva. In this case, the iris remains viable for a long time. The pupil appears peaked in the region of the iris prolapse. The anterior chamber is formed as the prolapsed iris seals the wound. 9inimal or no wound leakage occurs. -ound leak is verified using the !eidel test. A drop of ,: fluorescein sodium is instilled in the con1unctival sac. The wound is e%amined under the slit lamp with cobalt blue light. The fluorescein appears greenish. -ound leak can be easily identified when the fluorescein is diluted by the a.ueous humor. ;entle pressure on the eye may be needed to induce leakage. Intraocular pressure is lower than normal, but hypotony is uncommon after iris prolapse. In long$standing iris prolapse, chronic iridocyclitis, cystoid macular edema, or glaucoma may be seen. The prolapsed iris may act as a scaffold for infection, epithelial downgrowth, or fibrous ingrowth. <arely, sympathetic ophthalmia may occur. =arefully e%amining the fellow eye for cells and flare is important.

=auses
Iris prolapse can occur following trauma, after surgery, through a perforated corneal ulcer, or through a corneal melt.

edical =are
Iris prolapse is a serious condition that re.uires prompt medical management. As soon as the diagnosis is made, an eye shield should be applied to prevent further damage. 9edical treatment is only indicated when the prolapse is small, is covered by the con1unctiva, and is without any other complications. In these cases, the eye may be observed. Antibiotic eye drops and cycloplegics may be used during the acute stage. Intravenous antibiotics should be considered because infection from an iris prolapse can spread to the intraocular contents. Tetanus to%oid may be considered depending on the immuni&ation status and the wound type.

!urgical =are
)rompt surgical management is necessary when con1unctival coverage is not present or in the presence of complications. The primary goal of surgery is to restore the anatomical integrity of the eye. >isual restoration is only a secondary goal.'3( ;eneral anesthesia should be used during surgery. <etrobulbar anesthesia and peribulbar anesthesia are not recommended because they increase both intraorbital pressure and loss of additional intraocular tissue; however, they may be used if general anesthesia is contraindicated. In cases of peripheral iris incarceration and a well$formed anterior chamber, acetylcholine (9iochol" may be administered. o Acetylcholine is instilled through a paracentesis incision into the anterior chamber with gentle stroking of the iris. Acetylcholine constricts the pupil and may release the iris incarceration.

!imilarly, if the iris incarceration is central, intraocular epinephrine may be administered. /pinephrine dilates the pupil and helps to release the iris incarceration. If unsuccessful through a paracentesis incision, a viscoelastic agent is in1ected into the anterior chamber in the region of the iris prolapse. This mechanical force may be enough to release the prolapse and to reposition the iris. o If the prolapse occurred within the previous ,?$3@ hours and if the iris is viable, the iris is reposited. o If the iris does not appear viable, then it is e%cised. The iris should be e%cised if signs of epitheliali&ation are present. o To e%cise, the prolapsed iris is cut flush with the corneal surface. The iris defect may be closed using a #4$4 polypropylene suture on a vascular needle. If the viscoelastic method is unsuccessful, then a cyclodialysis spatula with the longer end is introduced through the paracentesis incision. The spatula is swept from the center to the periphery of the prolapse to avoid unnecessary tension on the iris root. The corneal wound may be sutured depending on its length and integrity. If the iris prolapse occurs after surgery, the same principle is used. The wound must be revised, or additional sutures should be applied to make the wound watertight. -hen the iris prolapse occurs after a corneal perforation, the iris can be reposited. =yanoacrylate glue and a bandage contact lens may be used to seal the perforation. If unsuccessful or if the perforation is large, an emergency corneal transplant is necessary. o

=onsultations
In patients with a corneal melt due to medical causes (eg, rheumatoid arthritis", appropriate consultations must be obtained.

Activity
The patient should not engage in contact sports because even a minor trauma can cause significant damage in an already compromised eye. The patient should be instructed to wear polycarbonate eyeglasses while working with mechanical devices and tools. Proceed to Medication

9edication !ummary
!ystemic antibiotics are used for prophyla%is against infection, especially in cases of iris prolapse following trauma. /ndophthalmitis is uncommon but has a poor prognosis in the setting of ocular trauma. Antibiotics should cover both gram$negative organisms and gram$positive organisms, including Bacillus, which is the most common cause of posttraumatic endophthalmitis.

Antibiotics
Class Summary
)rophyla%is against infection.
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Vancomycin (Vancoled Vancocin !y"#ocin$

)rovides e%cellent coverage of gram$positive organisms, including Bacillus. To avoid to%icity, current recommendation is to assay vancomycin trough levels after third dose drawn 4.+ h prior to ne%t dose. 0se creatinine clearance to ad1ust dose in patients with renal impairment.
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Ce%ta&idime ('a&idime Forta& Ce"ta& 'a&ice%$

Third$generation cephalosporin with broad$spectrum, gram$negative activity; lower efficacy against gram$ positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin$binding proteins.

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(ati%loxacin o"#t#almic ()ymar$

Auinolone that has antimicrobial activity based on ability to inhibit bacterial 85A gyrase and topoisomerases, which are re.uired for replication, transcription, and translation of genetic material. Auinolones have broad activity against gram$positive and gram$negative aerobic organisms. 8ifferences in chemical structure between .uinolones have resulted in altered levels of activity against different bacteria. Altered chemistry in .uinolones result in to%icity differences.
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Moxi%loxacin o"#t#almic (Vigamox$

Indicated to treat bacterial con1unctivitis. /licits antimicrobial effects. Inhibits topoisomerase II (85A gyrase" and I> en&ymes. 85A gyrase is essential in bacterial 85A replication, transcription and repair. Topoisomerase I> plays a key role in chromosomal 85A portioning during bacterial cell division. Proceed to Follo*+u"

urther Inpatient =are

After surgery, patients may be monitored on either an inpatient basis or an outpatient basis. Admitting patients for at least # day after surgery is recommended.

urther Butpatient =are

=orneal sutures may be removed when they become loose or in stages after ?$@ weeks. Cong$term follow$up care is necessary to monitor intraocular pressure and cataract formation. In patients who are medically treated, the eye should be carefully e%amined for iritis and cystoid macular edema. The fellow eye should be carefully e%amined for signs of sympathetic ophthalmia.

Inpatient D Butpatient 9edications

)ostoperatively, patients are prescribed antibiotics, steroid drops, and cycloplegics for 3$@ weeks.

8eterrenceE)revention
The patient should be instructed to wear protective eyeglasses that cover the eye from the front and the sides while working with mechanical devices and tools or during contact sports. (The author recommends avoiding contact sports." The protective eyeglasses should be made of polycarbonate, a shatterproof material.

=omplications
!everal complications can occur because of an iris prolapse, as followsF The prolapsed iris may act as a scaffold and introduce intraocular infection, such as endophthalmitis. If left untreated, the prolapsed iris becomes covered by epithelial and fibrous tissue, which may then grow into the eye. Although rare, sympathetic ophthalmia can occur. Iritis and cystoid macular edema can result from traction on the iris tissue. !econdary glaucoma may occur as result of iritis, synechiae, or epithelial downgrowth.

)rognosis
)rognosis depends on several factors. The smaller the prolapse, the better the prognosis. )atients with other in1uries and intraocular foreign bodies are likely to have a poor prognosis. The presence of infection carries a poor prognosis. /pithelial downgrowth and fibrous ingrowth are difficult to treat and have a poor prognosis.

)atient /ducation

or e%cellent patient education resources, visit e9edicine6ealth7s /ye and >ision =enter. Also, see e9edicine6ealth7s patient education article /ye In1uries.