CASE REPORT

Management of post-goniopuncture iris herniation:a two-step procedure

Julio Gonzalez Martın-Moro •

Yolanda Fernandez Miguel

Received: 27 March 2013 / Accepted: 28 May 2013

� Springer Science+Business Media Dordrecht 2013

Abstract A 38-year-old male presented to the emer-

gency room suffering acute pain in his left eye. Two

months before he had been submitted to uneventful non-

penetrating deep sclerectomy and one month before to

YAG-laser goniopuncture. Examination showed iris

herniation into the trabeculo-descemet’s window. Sur-

gical reduction was carried out through a peripheral

corneal incision, and a large air bubble was injected into

the anterior chamber. Four days later a wide laser

peripheral iridotomy was performed. This technique can

transform a non-penetrating technique into a full-

trabeculectomy, without reopening the superficial flap.

Keywords Non-penetrating deep sclerectomy �Laser goniopuncture � Iris herniation � Open angle

glaucoma � Surgical complications

A 38-year-old male was diagnosed with pigmentary

glaucoma. Visual fields only showed an initial defect

in his left eye, but intraocular pressure (IOP) was

28 mmHg, in spite of maximal treatment with travo-

prost, timolol 0.5 % and brimonidine.

Unsuccessful iridotomies and trabeculoplasty had

been previously performed, so the patient was sub-

mitted to an uneventful non-penetrating deep sclerec-

tomy, with removal of the Schlemm’s canal,

mitomycin C and intrascleral Esnoper� implant

(AJL Ophthalmics, Alava, Spain). IOP was 12 mmHg

on the first day of examination; however, 2 weeks later

the IOP rose to 34 mmHg, despite the presence of a

diffuse subconjunctival bleb. After demonstrating that

the IOP rise was not related to postoperative steroid

treatment, a successful goniopuncture was performed

1 month later. IOP remained controlled for the

following two visits (10 and 12 mmHg, respectively).

Two months after surgery the patient felt a sharp

pain in his left eye, and noticed that his pupil had

acquired a pear shape (Fig. 1). IOP was 49 mmHg in

his left eye. Treatment with intravenous mannitol, oral

acetazolamide, topical timolol 0.5 % and brimonidine

reduced the IOP to 32 mmHg. Iris prolapse into the

trabeculo-descemet’s window (TDW) was confirmed

by gonioscopy (Fig. 2), and pharmacological reduc-

tion of the herniated tissue was attempted using

several drops of pilocarpine 2 %. However the iris

tissue remained prolapsed, so surgical reduction was

carried out through a peripheral corneal incision, and a

large air bubble was injected into the anterior chamber

(Fig. 3). The patient was maintained on pilocarpine

drops and 5 days later a superior laser peripheral

iridotomy (LPI) was performed (Fig. 4). Seven shots

of 8 mJ were necessary to destroy the previously

herniated iris tissue. At the last visit, 6 months after

J. G. Martın-Moro (&) � Y. F. Miguel

Department of Ophthalmology, University Hospital

of Henares, Av. Marie Curie sn, 28820 Coslada, Madrid,

Spain

e-mail: juliogazpeitia@gmail.com

J. G. Martın-Moro

University Francisco de Vitoria, Madrid, Spain

123

Int Ophthalmol

DOI 10.1007/s10792-013-9810-y

hernia reduction, the IOP was 16 mmHg without

treatment, and the TDW remained opened and free of

iris tissue (Fig. 5). Visual acuity remained 20/20 in

both eyes, and despite the cataractogenic effect of

surgery, intraocular air, steroid treatment and laser,

only tiny superior anterior subcapsular opacifications

(similar to glaucoma flecks), were observed at the last

examination (Figs. 6, 7).

Iris herniation remains one of the most severe and

challenging complications of non-penetrating glau-

coma surgery. It can occur spontaneously [1] or after

laser goniopunction. Although not uncommon, only a

few cases of iris herniation related to goniopuncture

have been reported (in one of the larger published

series, Vuori [2] reported this complication in three

out of 31 patients) and there is no consensus on the best

way to handle this problem.

Fig. 1 Elongated pupil on the first day examination

Fig. 2 Gonioscopy showed a wide iris herniation into the

goniopuncture

Fig. 3 An air bubble was injected into the anterior chamber to

stabilize the iris

Fig. 4 A wide LPI was performed to eliminate the herniated

iris

Fig. 5 Gonioscopy showing a wide ostium on the TDW

(6 months after iris herniation)

Int Ophthalmol

123

It is difficult to identify the risk factors involved in

this complication. However, the three patients

reported by Vuori had very high pre-goniopuncture

pressures (39, 35 and 28 mmHg), and all of them

experienced a substantial reduction of IOP. In their

study, they did not compare the mean pre-laser

pressure between those who suffered and those who

did not suffer this problem. However, it seems

plausible that a very successful goniopuncture in an

eye with a high pre-goniopuncture IOP places the

patient at a higher risk of developing this complica-

tion. The three patients in the study by Vuori were

successfully managed by reopening the superficial flap

and performing a surgical iridectomy.

In a recent paper, Anand and Pilling [3] suggested

some recommendations to minimize the risk of

incarceration—avoid goniopuncture in phakic eyes

with shallow anterior chambers and a convex periph-

eral iris; avoid anterio-posteriorly narrow windows;

wait at least 1 month to perform the goniopuncture;

and perform small punctures, preferably in the anterior

edge and the lateral sides of the window.

In our case, this serious complication was managed

in a safer way, without opening the surgical flap.

Although reduction of the hernia is difficult because

this tissue has lost its mechanical properties and tends

to reincarcerate, injecting an air bubble can be very

useful to avoid reherniation. The combination of air

pushing the iris backwards and pilocarpine pulling it

towards the center of the anterior chamber creates a

diagonal vector that is very effective in preventing iris

reherniation. In our case, the LPI was performed

4 days later; however, we think that performing the

iridotomy on the first postoperative day through the air

bubble might have been an even better approach.

The injection of air into the anterior chamber has

demonstrated its utility in several anterior segment

procedures. On the one hand, it can help to tamponade

Fig. 6 Lens of both eyes

showing no progression of

cataract (6 months after iris

herniation)

Fig. 7 Tiny superior subcapsular opacifications, similar to

glaucoma flecks, were observed at the last examination

(6 months after iris herniation)

Int Ophthalmol

123

IOP fluctuations [4], and some experimental studies

have even demonstrated anti-inflammatory and anti-

bacterial effects [5, 6]. On the other hand, some works

have demonstrated that air may have a cataractogenic

effect. Air bubble-induced anterior subcapsular opac-

ification has been observed after descemet’s mem-

brane endothelial keratoplasty in phakic eyes

(attributed to air bubble misdirection) [7], and after

trabeculectomy (when sector iridectomies are per-

formed) [8]. In our case, only half of the anterior

chamber was filled with air and myosis prevented air

contact with the anterior surface of the lens. No

progression of cataract or worsening of visual acuity

was observed during the first 6 months after iris

herniation. We think that probably the traditional

approach to this complication (reopening the superfi-

cial flap and performing a surgical iridectomy) may be

associated with a higher cataractogenic effect.

As this complication is severe, and not uncommon,

in eyes with high pre-goniopuncture IOP and very

effective reduction of IOP, a prophylactic combined

Nd-YAG goniopuncture-iridotomy could be a safer

technique than an isolated goniopuncture. Qing et al.

[9] reported a similar case in which iris herniation

recurred despite LPI; however, they performed a

narrow LPI, aiming to equilibrate pressures between

chambers and not to eliminate the previously herniated

iris. More studies are needed to confirm that this

method is not associated with a higher risk of

sinequiae formation or cataract progression. However,

this double laser procedure can safely transform a non-

penetrating technique into a full-trabeculectomy,

reducing the risk of iris herniation.

Conflict of interest None.

References

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