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September 2013 EW NEWS & OPINION 15 Anterior segment grand rounds Where's the pupil? by Steven G. Safran, MD T his is an 85-year-old woman who had ECCE back in the 1980s. She had been on pilocarpine for many years to treat glaucoma, but that was discontinued over a decade ago as she had no glaucoma damage and her IOP was always acceptable off medication. She has been off all glaucoma medication for more than five years. Her pupils were always relatively small and poorly reactive due to the previous longstanding use of pilocarpine, but she had been very stable for the 12+ years I'd been treating her with normal IOP, 20/20 vision, and no inflammatory issues. After she was admitted to a nursing home she had missed a few appointments, but her family brought her in to see me one day for an emergency visit with "acute visual loss." The vision in her right eye was bare light perception, while the left was 20/20. When I examined her at the slit lamp, she had complete absence of the pupil. A membrane had grown over her pupil, completely obliterating it. There was no sign of inflammation, and her IOP was 16. I could not assess her for a relative afferent pupillary defect because her other eye had a fixed 2–3 mm pupil from her years of pilocarpine use. The pupil was completely occluded with not even a pinhole crack opening (Figures 1 and 2). Steven G. Safran, MD, Anterior segment grand rounds editor I discussed this case with John Hart, MD, professor of ophthalmology, Oakland University, William Beaumont School of Medicine, and co-chair of anterior segment surgery, William Beaumont Hospital, Royal Oak, Mich.; Joanna Fisher, MD, chief of ophthalmology, Holy Redeemer Hospital, and in private practice, Valley Eye Professionals, Huntingdon Valley, Pa.; Michael Sulewski, MD, co-director, cornea service, Scheie Eye Institute, and chief of ophthalmology, Philadelphia VA Medical Center, Philadelphia; and John Doane, MD, refractive and corneal surgeon, Discover Vision Centers, and clinical assistant professor, Department of Ophthalmology, Kansas University Medical Center, Kansas City, to get their thoughts about what might have contributed to this patient's problem and how they might proceed in managing this case. Dr. Sulewski commented: "I would recommend doing a B-scan ultrasound first to ensure there is no obvious posterior pathology such as retinal detachment (RD), cupped out nerve, or other problems. You could also do entoptic testing with a penlight, which is a rough indicator of some degree of optic nerve function. Then, if confident that there is some visual potential or to get a better view of the fundus, go forward with a YAG anterior membranotomy, starting at a power of about 1 mJ and increasing as necessary to get through the membrane. This should be enough to get a view in and hopefully see how well the patient can see out. If you are unable to get through with the laser, then take the patient to the OR for excision and stretching the pupil open a bit and lysing some of the longstanding posterior synechiae caused by the years of being on pilocarpine." Dr. Hart had similar thoughts: "I would first get a B-scan to rule out posterior segment pathology like a retinal detachment or tumor and then an ultrasound biomicroscopy (UBM) to better define what might be lurking behind the membrane that is occluding her pupil. If the Bscan and the UBM are normal then I would consider using a YAG laser to make an opening in the membrane occluding the pupil. One could also consider stripping the membrane Figures 1 and 2: The pupil is completely obliterated by fibrotic membrane. Not even a pinhole opening is present here. Figures 3 and 4: The patient's vision was 20/20 immediately after YAG dissection and disruption of fibrotic membrane. from the pupil margin. This could be done from an anterior approach using MST (Redmond, Wash.) micrograspers." Dr. Fisher would also do a Bscan and then attempt to treat this patient with YAG laser. "Interesting case. I have a patient like this who developed a pupillary membrane secondary to vitreoproliferative disease and traction RD. She is LP but retina has not recommended any more intervention. In this patient I would start with a B-scan to rule out RD, mass, etc. If the posterior segment looks OK, I would consider YAG laser to make an opening in the membrane. "On the picture, the iris looks to be bowing forward. Does this patient have a PI? If unable to open the membrane with a laser, surgical consideration can be given. After injection of viscoelastic, I would try to break up the membrane with a cystotome or some other sharp instrument (MST scissors may work well). Hopefully that would be successful to re-establish a visual axis." Dr. Doane, in his consideration of this case, had concerns about possible associated systemic issues here: "The sudden loss of vision to the level of light perception in an elderly female raises my concern for a central arterial or venous occlusion or an arteritic or non-arteritic ischemic optic neuropathy. The inability to visualize the posterior pole limits valuable ophthalmoscopic information to narrow the diagnosis. We are at a crossroads. Does this patient have a completely normal retina and optic nerve and just a very dense pupillary membrane (from whatever cause) leading to light perception vision? This would be a wonderful situation if it were the case. Nevertheless, I do think this patient needs a basic blood and systemic inflammatory/vascular workup for arterial/venous occlusive disease with evaluation of her carotid arteries, if not already known. B-scan ultrasonography should be completed to assess retinal attachment or not. During the Bscan ultrasonography, any detail of the IOL and proximal anatomy should be evaluated. The easiest part of this case is the what to do, but an important point to consider would be does the patient want anything done? Can she function monocularly as she has done over the last year? Is she incapacitated or not by this? If she is functioning fine, I would not push the option of surgery. If she is bothered and she has continued on page 16