A 64-year-old female presented with gradual loss of vision in the right eye (OD) of one year duration. About six months ago, she had undergone intracapsular cataract extraction, anterior vitrectomy, and scleral fixation of intraocular lens (IOL) in the left eye (OS). At that time, she was suspected of iridocorneal endothelial syndrome (ICES).\nThe preoperative best corrected visual acuities (BCVA) were 20/400 OD, 20/30 OS. Intraocular pressures (IOP) in each eye were 15 mmHg by applanation. The Slit lamp biomicroscopy of both eyes (OU) showed clear cornea, deep and clear AC, and the angle was wide open. Both eyes had splitting of the anterior layers of the iris with fibrillar degeneration extending from 3 to 6 o' clock OD, and from 4 to 6 o' clock OS. Additionally, there was diffuse atrophy of iris from 11 to 1 o' clock OS (). The underlying iris pigment epithelium appeared intact with no transillumination defect. The clinical appearance was consistent with iridoschisis OU. The right eye showed nuclear and cortical cataract associated with posterior subcapsular cataract, and the left eye was pseudophakia. Specular microscopy of the OD revealed regular, hexagonal shape of endothelial cells without any abnormalities like bullae or guttae, and the endothelial cell count was 2865 cells/mm2. The rest of the ocular examination was normal.\nPupil dilation is performed using 3 drops of tropicamide 0.5% and phenylephrine hydrochloride 0.5% at 5-minute intervals 1 hour prior to surgery. Intraoperative pupillary diameter was about 5~6 mm. Topical anesthesia was applied using Alcaine® and 3% Lidocaine, and a paracentesis was done at 10 o' clock. A 2.75 mm main clear corneal incision was performed using the keratome blade. A dispersive ophthalmic viscosurgical device (OVD), sodium hyaluronate 3%-sodium chondroitin sulfate 4% (Viscoat®, Alcon) was injected through the clear corneal wound to stabilize the anterior chamber and protect the iris stroma by displacing aqueous from the AC and pushing the iris strands from the pupillary aperture. An anterior continuous curvilinear capsulorhexis not exceeding over the pupillary margin was performed using the 26 G needle and capsular forceps. After hydrodissection and hydrodelineation, careful phacoemulsification was performed (Allergan Sovereign® Phaco System, SOV680330) for nucleus removal with special care not to touch the iris tissue. Aspiration was used to clean residual cortical fibers from the capsular bag. When a loss of the protective effect of viscoelastic material was observed during surgery, Viscoat® was reinjected additionally to inhibit iris fibril movement with the BSS stream.\nThe maximum limit of the vacuum was 300 mmHg and the aspiration rate, 20 cc/mmHg. The height of the irrigation bottle is maintained less than 60 cm to minimize the turbulence within the chamber. Total US time was 48 seconds with a mean final rate of 10% of potency.\nThe capsular bag was inflated with viscoelastics, and a single-piece acrylic intraocular lens (Acry-Sof® SA60AT, Alcon) was inserted. The IOL was safely placed in the capsular bag and centered, followed by aspiration of the residual viscoelastics. If there were some movement of iris fibrils, additional viscoelastics was inserted.\nFinally, BSS Carbacol (carbachol 0.01%, Miostat®) was used to constrict the pupil.\nPostoperatively, the inflammatory response in the AC was moderate, some fibrillar materials were seen. The cornea showed some Descemet folds, and the pupil was round and undamaged ().\nOne week after surgery, the uncorrected visual acuity was 20/100 OD, and improved to 20/30 on the two weeks postoperative day. There were traces of cells in the AC, but no fibrillar materials were seen ().\nThe patient's last visit was 1 month after surgery when UCVA was 20/40, and BCVA 20/20. The cornea, AC and iris were clear and intact without any inflammatory sequalae.
Case 3 involved a 66-year-old male who was referred to our clinic because of visual loss with congestion and intermittent pain in the left eye for the preceding six months. The patient had no history of ocular trauma or heritable ocular disease.\nThe result of a RPR test for syphilis was confirmed to be a false positive. The preoperative BCVAs were 20/125 OD and 20/50 OS. The IOPs were 22 mmHg OD and 35 mmHg OS. Slit-lamp examination revealed a local rupture in the temporal quadrant of the iris stroma of the right eye (Fig. ). In the left eye, the anterior layer was divided into a loose mixture in the temporal iris and the AC was of normal depth (Fig. ). A postmydriatic examination showed cortical opacity of the lens and dust turbidity of the vitreous body. Gonioscopy showed that the peripheral AC in the superior area of the right eye had a discontinuous synechia along together with pigment deposition (Fig. ). Scheimpflug images by Sirius showed that part of the peripheral AC was shallow and that the iridocorneal angle was still open in both eyes (Figs. ). The endothelial cell counts were 3,306 cells/mm2 OD and 3,011 cells/mm2 OS. The patient was diagnosed with secondary glaucoma with iridoschisis and received BAK-free travoprost 0.004% containing polyquaternium-1 (Travatan® preserved with POLYQUAD®, Alcon Laboratories, Fort Worth, TX, USA) once daily and brinzolamide (Azopt®, Alcon, Laboratories, Elkridge, MD), 2% carteolol (Mikelan®, China Dazhong pharmaceutical Co., Ltd, Tianjin, China), and alpha2-agonist (Alphagan®, Allergan, Inc., Irvine, CA) twice daily.\nOne month after admission, over which time the eye drops were used, the IOPs were 18 mmHg OD and 32 mmHg OS. The IOPs showed significant fluctuation with medical treatment. Notably, glaucoma surgery will be necessary for this patient in the future. The patient was advised to have frequent ophthalmologic examinations to monitor the IOPs in his eyes and to assess any progression of glaucomatous changes in both eyes.