Eyes with ICE syndrome are notoriously difficult to manage over the long term. In the spectrum of ICE syndromes, Figure 1 appears to fit with the essential iris atrophy group with a minimum of corneal involvement. Information that would be helpful in the decision process is the health of the optic nerve and how long IOP had been stable on the regimen. For this discussion I will assume there has been optic nerve damage.
Surgical management has many options. The first would be clear corneal temporal phacoemulsification with IOL implantation. Cataract extraction in eyes with ICE is not difficult once the iris abnormalities are managed. The difficulty with this plan is that the glaucoma may become more difficult to manage. If the nerve is healthy, cataract extraction alone may be a good option; however, with ICE, chances are that the glaucoma will become more difficult to manage.
Another option would be a nonpenetrating procedure such as viscocanalostomy with temporal clear corneal cataract extraction. There are no reports of this combination. The pathophysiology of ICE might render this a short-term success.
Another option would be ciliary body laser ablation with the cataract extraction. Again, no studies have been reported. The inflammation of the procedure may lead to a difficult postoperative recovery.
I have had reasonably good results with trabeculectomy using mitomycin-C at 0.2 mg for 2Symbol to 3 minutes combined with a temporal clear corneal cataract extraction. A 2-site approach is used. In this eye, I would start with a fornix-based peritomy superiorly. A 4.0 × 2.0 mm 300 μm scleral flap would be dissected. A pledget of mitomycin-C, 0.2 mg/cc, would be placed under Tenon's and above the scleral flap. The edges of the conjunctiva would be lifted from the sponge. When the mitomycin sponge is on the eye, the microscope and foot pedals would be rotated, the sponge removed, and the space copiously irrigated.
I would then make a parcentesis and inject unpreserved lidocaine 1%. In this eye, I would expect the pupil would not dilate well, and the “art” of this case would be pupil management. Stretching is my usual procedure, but with ICE syndrome, this tends not to work well. In this setting, I would use either Grieshaber iris retractors or a Graether silicone pupil expander. Once the iris has been dealt with, surgery is usually not too difficult. A standard central capsulorhexis is performed followed by phacoemulsification with IOL implantation. After that, I would move superiorly and complete the trabeculectomy.