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 1 involved a 69-year-old male who presented with one month of blurred vision and an exacerbation of this blurred vision for the preceding ten days in the right eye (OD). The patient had no history of ocular trauma or heritable ocular disease. He had been suffering from hypertension for 15 years and was receiving antihypertensive treatment.\nThe result of a rapid plasma reagin (RPR) test for syphilis was negative. A clinical examination showed that the preoperative uncorrected visual acuities (UCVA) were hand movement OD and 20/40 for the left eye (OS). The IOP in each eye was 13 mmHg. Slit-lamp biomicroscopy showed that the anterior layer of the iris stroma (OD) was divided into a loose mixture of numerous pigmented and white atrophic strands, which ran in all directions and thus presented an interlaced pattern. The distal ends of the fibrils were attached to the ciliary portion and were floating freely in the aqueous humour (Fig. ). The underlying iris pigment epithelium appeared imperfect, which indicated the transillumination defect, and the exfoliating iris pigment epithelium accumulating in the AC could also be observed. The right eye showed a mature cataract that hindered visualization of the fundus and evaluation of any optic disc alterations. A slit-lamp examination of the left eye revealed inferior-nasal iridoschisis, which presented from the 5 to 9 o’clock positions and had a normal AC depth (Fig. ). Scheimpflug image by Sirius (Costruzione Strumenti Oftalmici, Florence, Italy) showed that the local AC was extremely shallow in the right eye (Figs. ). The endothelial cell counts were 3,453 cells/mm2 OD and 3,738 cells/mm2 OS.\nPhacoemulsification (PHACO) was first performed on the right eye and was then conducted on the left eye one month later. During surgery, the freely floating iris fibrils were cut with Vannas capsulotomy scissors. A foldable hydrophobic acrylic IQ intraocular lens (IOL) (Acry-Sof® SN60WF, Alcon Laboratories Inc.) was safely implanted in the capsular bag. Postoperative examinations were conducted at 1, 7, 30, and 60 days following the procedure.\nOne day after the surgery on the right eye, the UCVA of the right eye was FC/30 cm, and the IOP was 13 mmHg. A slit-lamp examination showed moderate ocular hyperaemia and corneal oedema. The AC depth was normal, and the pupil was round and undamaged. One week after surgery, the UCVA was 20/50 and the IOP was 15 mmHg. The ocular hyperaemia had disappeared, and there was mild corneal oedema that was improving. One month after surgery, the UCVA was 20/40 and the IOP was 17 mmHg (Fig. ). Two months after surgery, the UCVA was 20/30, the IOP was 17 mmHg, and the endothelial cell count was 1,085 cells/mm2.\nOne month after the surgery on the right eye, PHACO was performed on the left eye without additional treatment to the iris. One day after the surgery on the left eye, the UCVA in that eye was 20/32, and the IOP was 16 mmHg. A slit-lamp examination showed no obvious postoperative reaction. One week after surgery, the UCVA was 20/30 and the IOP was 17 mmHg. One month after surgery, the UCVA was 20/25 and the IOP was 16 mmHg (Fig. ). The endothelial cell count was 2,630 cells/mm2 at that time. Two months after surgery, the UCVA was 20/25, the IOP was 14 mmHg, and the endothelial cell count was 3,618 cells/mm2. Although the postoperative corneal endothelial cell density remains normal, the coefficient of variation > 30.