Lumi et al. described a combined approach of traumatic mydriasis repair and retro fixed iris-claw lens in their article. In their article, although they have clearly described the technique for iris repair and intraocular lens (IOL) fixation, some focus should also be given to the anterior segment damage and high intraocular pressure (IOP) management. IOP in the range of 53, 72, and 63 mmHg with hyphema may not always be controlled with topical antiglaucoma medication alone. The duration of hyphema, the extent of hyphema, and high IOP also hold importance in the management as the longer duration of hyphema leads to trabecular meshwork dysfunction, which is always not reversible. All the patients with blunt trauma with closed globe injury should be assessed for angle recession as a late cause of glaucoma as the chance of angle recession is 20% to 94%, whereas if associated with hyphema there is a 70% to 100% chance of angle recession. Angle recession glaucoma may develop in two peaks: one around 3 months and the other after around 10 years. So long-term observation is required in these cases. Hence in the majority of these cases with high IOP, trabeculectomy with mitomycin C may be needed for IOP control and long-term IOP management to prevent optic nerve damage.
Again, high IOP in the range of 70 mmHg and corneal edema indicate corneal decompensation, if it is for a longer period. In these cases, if IOP is not controlled immediately, there may be permanent corneal decompensation in that eye where already there is vitreous hemorrhage, and the anterior hyaloid face may be disturbed increasing the possibility of vitreous coming near the cornea and also the trabecular meshwork. So the timing of appropriate intervention may prevent the above complications in this type of high-impact closed globe injury cases where there is lens dislocation, vitreous hemorrhage, and hyphema.
Another point to be noted is that after 360° encircling with prolene suture making the pupil size 3.5 to 4 mm wide, there may be a possibility of cheesewiring of iris tissue when the IOL is pushed through the pupil for retro fixation because of the rigid IOL. So postoperative stability of IOL is also a challenge to the surgeon.
1. Lumi X, Lumi A, Petrovic Pajic S. Iris cerclage pupilloplasty and IOL implantation for traumatic mydriasis and aphakia after the blunt trauma of the eye Indian J Ophthalmol . 2021;69:1314–7
2. Tönjum AM. Gonioscopy in traumatic hyphema Acta Ophthalmol (Copenh) . 1966;44:650–64
3. Tumbocon JA, Latina MA. Angle recession glaucoma Int Ophthalmol Clin . 2002;42:69–78
4. Manners T, Salmon JF, Barron A, Willies C, Murray AD. Trabeculectomy with mitomycin C in the treatment of post-traumatic angle recession glaucoma Br J Ophthalmol . 2001;85:159–63