Managing Pupillary Block after Descemet Stripping Endothelial Keratoplasty Dorota Tarnawska, MD, Dariusz Dobrowolski, MD, Dominika Janiszewska, Edward Wylegala, MD, PhD

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Managing Pupillary Block after Descemet
Stripping Endothelial Keratoplasty
Dorota Tarnawska, MD Dariusz Dobrowolski,
MD Dominika Janiszewska Edward Wylegala, MD, PhD
Dept. of Ophthalmology, District Railway
Hospital, Katowice, Poland
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• Authors do not have any financial interest or
  relationship to disclose

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Purpose

• Pupillary block is the potential complication
  resulting from forward or backward iris movement
  causing by residual air bubble in Descemet
  Stripping Endothelial Keratoplasty (DSEK) eyes.
• We described the management of pupillary block
  of two different mechanisms after DSEK.

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Block mechanisms

• Anterior block (A) air prevents aqueous drainage
  through the iris fluid collected behind the
  peripheral iris closes the angle.
• Posterior block (P) air behind the iris
  displaces it forward and sticks to the cornea.

P
A
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Methods

• All patients with posterior air misdirection
  were treated with iris dilation and head
  positioning (lifting).
• Partial blocks were also treated with head
  position.

Partial posterior block Only inferior iris
stuck to cornea Treatment pupil dilation head
lifted at a 45º angle with reference to bed
surface gravitational block release
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Methods
Partial posterior block Only superior iris is
stuck to cornea Treatment pupil dilation head
positioned at a 45º angle with reference to bed
surface (with beard a few cm higher than
head) gravitational block release
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Posterior block - air behind the iris pushes it
forward and sticks to the cornea.
Case 1. Endothelial lenticle thinning graft is
compressed with air.
Case 2. Peripheral iris-graft touching (arrow).
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Methods

• In eyes with ineffective head positioning
  surgical intervention was necessary
• in eyes with anterior pupillary block the excess
  of air was remove via paracenhtesis in
  pseudophakic and via pupil in aphakic eye.
• in pseudophakic eyes with posterior pupillary
  block surgical synechiolysis with iridectomy was
  performed to decrease IOP.

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Results

• Among 136 DSEK eyes in 23 (17) air bubble
  misdirection was observed on 1-3 postoperative
  days.
• In 18 eyes (13) appropriate head positioning was
  an exclusive and effective treatment.
• In 5 eyes (4) additional interventions were
  necessary to break pupillary block.
• In all surgically treated eyes pupillary block
  was successfully broken.
• In 1 eye a fibrin-like membrane formation in the
  pupillary opening was observed.

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Conclusions

• In the majority cases of air misdirection head
  positioning is a sufficient method for preventing
  pupillary block.
• The remaining can be effectively treated
  surgically regarding of block mechanism.