The Acute And Surgical Management Of An Anteriorly Vaulted Sulcus Iol Causing Pupillary Block

To highlight a case of anterior vaulted IOL and discuss the acute management options as well as long term management including surgical intervention. 

A clinical case seen in the emergency ophthalmology department in a district general hospital in United Kingdom.

We report a case of a 54 year old female who presented to eye casualty with a painful red eye with reduced vision (6/36 from 6/6) and a distorted pupil. Examination revealed an anteriorly vaulted optic of a 3-piece IOL. The lens was found to be inserted upside down, in the “S” configuration leading to anterior displacement of the optic, pupil block and subsequent raised intra-ocular pressure of 60mmHg. The use of mydriatics and lying the patient supine allowed the optic to fall behind the iris plane and thus address the pupil block. The patient was also listed for surgery in order to correctly place the lens in the correct orientation. Our patient did well with intra-ocular pressure stabilising and a final visual outcome of 6/4.

Care must be taken at the time of lens insertion to avoid such issues from arising. 

3-piece IOLs are designed in such a way to vault the optic towards the posterior capsule and so, if they are inserted upside down, the optic can vault anteriorly which can lead to problems such as pupillary block as well as refractive surprise. 

In the rare circumstance such a case presents to casualty, simply positioning the patient supine and administering a mydriatic can help to respoition the lens. Definitive management involves surgically re-position the lens which can either be by performing a lens exchange or an in-situ flip.