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(Data acquisition - Description of abnormalities)

This is an external photo of the patient’s left eye.  My attention is immediately drawn to the large area of iridodialysis inferiorly.  There is perhaps trace conjunctival injection and a moderate nuclear sclerotic cataract in this eye.

 

(Data acquisition - History to obtain)

I would ask the patient whether there was any antecedent trauma to this eye; whether there was ever a hyphema in this eye; whether he has undergone ocular surgery in this eye; and whether he has “double vision” or “jiggling vision” in this eye.  I would ask whether any parts of his vision are missing; whether he has any allergies to medications including sulfa medications; or any other past ocular or medical history.

(Data acquisition - Exam data to seek out)

I would perform a comprehensive exam of both eyes.  In particular, I would look for iridodenesis and transillumination defects; phacodenesis in this left eye; measure the density of the cataract; measure intraocular pressure; examine the optic discs for signs of glaucomatous optic neuropathy; and check for retinal breaks in the periphery.  I would perform gonioscopy to check for angle recession especially in this left eye.

You are told that the intraocular pressures are 15 and 30 mmHg in the right eye and left eyes respectively.  There is no phacodenesis

 

This is a gonioscopic view of presumably the inferior quadrant of the patient’s left eye.  There is an increased ciliary body band toward the center and left of the photo.  Thus, there appears to be angle recession of at least the inferior angle.

(Diagnosis -- Focused differential diagnosis)

There not really a differential diagnosis for this patient’s presentation.  This patient almost certainly has iridodialysis and angle recession most likely from ocular trauma.  But other things that could be considered in the differential diagnosis are:

• Iridodialysis and angle recession from intraocular surgery
• Cyclodialysis cleft
• Iridocorneal endothelial syndrome

What other tests would you want to order?

I would order static perimetry and OCT RNFL to determine if the elevated intraocular pressures have resulted in glaucomatous optic neuropathy.  If available, I could perform ultrasound biomicroscopy to determine if there was a cyclodialysis cleft.

(Management -- appropriate plan for medical or surgical management of condition)

My first priority would be to lower his intraocular pressure since the consequences of not doing so is irreversible optic nerve damage.  Thus, I first would start him on topical glaucoma drops.  If glaucoma drops did not succeed and oral glaucoma meds were not tolerated, then I would consider a glaucoma operation; for example, a filtering operation or a glaucoma tube.  If the cataract was visually-significant, then I would perform cataract surgery in conjunction with the glaucoma surgery.  If the iridodialysis was causing significant glare, then I would repair it using 9-0 Prolene suture using a modified Siepser knot technique.

(Management -- prognosis and/or therapeutic complications)

I would counsel the patient that the visual prognosis is quite good as long as there is not significant glaucomatous optic neuropathy.  I would also inform her that multiple glaucoma operations might be necessary to control her intraocular pressure adequately and that she may still need to instill glaucoma medications.  I would inform her that iridodialysis repair has very good results with resolution of significant glare symptoms in the majority of cases.