Anterior segment imaging in the management of postoperative fibrin pupillary–block glaucoma Wei-Boon Khor, MRCSE, Shamira Perera, FRCOphth, Aliza Jap, FRCS, Ching-Lin Ho, FRCSE, Sek-Tien Hoh, FRCSE Postoperative fibrin pupillary–block glaucoma, an uncommon complication of intraocular surgery, develops when an inflammatory fibrin membrane occludes the pupil, resulting in peripheral angle closure. We present a series of 4 patients with this condition and describe the role of anterior seg- ment optical coherence tomography and ultrasound biomicroscopy in distinguishing fibrin pupil- lary–block glaucoma from other forms of postoperative acute glaucoma. Specific to this condition is the presence of a fibrin membrane across the pupil and accumulation of aqueous in the poste- rior chamber, as would be expected in pupil block, but with a clear separation between the intra- ocular lens and the iris. The possible risk factors are discussed and various treatment modalities reviewed. J Cataract Refract Surg 2009; 35:1307–1312 Q 2009 ASCRS and ESCRS Intraocular pressure (IOP) elevation after intraocular surgery can be a potentially sight-threatening compli- cation. After cataract surgery, IOP elevation can be due to various causes ranging from retention of oph- thalmic viscosurgical devices in the immediate post- operative period to a hypertensive response from the prolonged use of topical steroid drops. Acute postop- erative IOP elevation may rarely be due to malignant glaucoma, capsular block syndrome, or pseudophakic pupillary block glaucoma. We present 4 patients in whom complete occlusion of the pupil by an inflammatory fibrin membrane re- sulted in acute postoperative pupillary-block glau- coma. We describe the clinical findings and highlight the role of anterior segment imaging in the diagnosis and management of these patients. CASE REPORTS Case 1 The patient was a 55-year-old Chinese man with poorly controlled diabetes mellitus, hypertension, hyperlipidemia, and a history of ischemic stroke. He had diabetic retinopathy with limited tractional retinal detachment that had been treated with panretinal photocoagulation 4 years previously. Uneventful phacoemulsification cataract surgery with intra- ocular lens (IOL) implantation was performed in the left eye. Intraoperatively, the pupil was noted to be small but pupil manipulation was not required to complete the surgery. On the first postoperative day, the visual acuity was 20/60 and anterior chamber activity was 2C cells; by day 4, ante- rior chamber activity had decreased to 1C cells with stable vision. The patient returned 2 weeks after surgery with a complaint of sudden pain and loss of vision for 1 day. Ex- amination showed an edematous cornea and elevated IOP of 58 mm Hg. There was uniform shallowing of the anterior chamber, with 360 degrees of peripheral iridocorneal touch. A fibrin membrane was present across the pupil and there was apparent forward displacement of the IOL. Anterior segment optical coherence tomography (AS- OCT) (Visante, Carl Zeiss Meditec) was performed (Figure 1). The anterior chamber was formed centrally. The fibrin mem- brane could be seen across the pupil, but there was no poste- rior synechia. The IOL was actually displaced posteriorly rather than anteriorly, with a large clear space between the IOL and the iris. The impression was pupillary-block glau- coma secondary to occlusion from the fibrin membrane. Despite intensive treatment with topical and systemic glaucoma medication, the IOP remained high. A sequential argon–neodymium:YAG (Nd:YAG) laser peripheral iridoto- my was performed that same day, with immediate deepen- ing of the anterior chamber and normalization of the IOP to 18 mm Hg. After 8 weeks, the fibrin membrane resolved completely and the IOP remained normal. Visual recovery was limited due to the underlying diabetic retinopathy. Submitted: October 15, 2008. Final revision submitted: February 14, 2009. Accepted: February 23, 2009. From the Singapore National Eye Centre (Khor, Perera, Jap, Ho, Hoh), and the Singapore Eye Research Institute (Khor, Perera, Ho, Hoh), and the Division of Ophthalmology (Jap), Changi General Hospital, Singapore, Republic of Singapore. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Sek-Tien Hoh (FRCSE), Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751 Republic of Singapore. E-mail: sthoh@pacific.net.sg. Q 2009 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/09/$dsee front matter 1307 doi:10.1016/j.jcrs.2009.02.034 CASE REPORT