Case Report Total Aniridia After Nonperforating Trauma of a Pseudophakic Eye Ultrasound Biomicroscopic Findings Francesco Parmeggiani, MD, PhD, Enrico Mantovani, MD, Ciro Costagliola, MD, Claudio Campa, MD, Piero Steindler, MD I n pseudophakic eyes, isolated total aniridia after nonperforating blunt trauma, without any apparent dehiscence or extension of the cataract incision, has been rarely reported in the literature.1–5 Here we describe a case of posttraumatic massive hyphema followed by complete aniridia in a patient who had undergone cataract surgery 18 months before. A comprehensive diagnostic assessment, including ultrasound biomicroscopy (UBM; ie, 50-MHz single-element mechanical sector scanner) was performed within few days of hyphema reabsorption. To our knowledge, UBM findings of this condition have not been documented previously. Case Report Abbreviations IOL, intraocular lens; UBM, ultrasound biomicroscopy Received July 26, 2007, from the Department of Ophthalmology, University of Ferrara, Ferrara, Italy (F.P., C.Ca.); Division of Ophthalmology, Unità Locale Socio Sanitaria 15 Alta Padovana, Camposampiero Hospital, Camposampiero, Italy (F.P., E.M., P.S.); and Department of Health Sciences, University of Molise, Campobasso, Italy (C.Co.). Revision requested July 31, 2007. Revised manuscript accepted for publication August 8, 2007. Address correspondence to Francesco Parmeggiani, MD, PhD, Sezione di Clinica Oculistica, Dipartimento di Discipline Medico–Chirurgiche Della Comunicazione e del Comportamento, Università Degli Studi di Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy. E-mail: francesco.parmeggiani@unife.it A 45-year-old man, affected by bilateral retinitis pigmentosa, had uneventful phacoemulsification in his left eye through a small temporal self-sealing clear corneal incision. An intraocular lens (IOL) was implanted in the capsular bag. At the end of the procedure, the wound was secure and left unsutured. Eighteen months after surgery, the patient fell in a dark room, heavily striking the left eye. Two hours later, at the emergency department of another institution, the globe appeared intact (Seidel negative), showing massive hyphema in the anterior chamber. The intraocular pressure was 28 mm Hg. B-scan echography did not show any sign of retinal detachment. The patient was treated with topical dexamethasone, atropine, and timolol, in addition to oral acetazolamide. As the blood partially subsided over the following 36 hours, intraocular structures become visible superiorly, revealing absence of the iris together with an undamaged capsular bag containing a stable IOL. After 4 days, during our first examination, complete aniridia on biomicroscopy, gonioscopy, and UBM was diagnosed (Figure 1). © 2007 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2007; 26:1795–1797 • 0278-4297/07/$3.50 Total Aniridia of a Pseudophakic Eye Discussion There are 2 possible explanations for the hitherto described aniridia secondary to traumatic iridodialysis: (1) the iris was expulsed through the quickly transient opening of the cataract incision; and (2) the iris remained within the eye, and then it was phagocyted by macrophages and/or trabecular meshwork cells. The first hypothesis has already been suggested by other authors, who have reported similar posttraumatic outcomes but always in eyes with recent cataract surgery.1,2,4 In particular, Lim and coworkers2 described iris expulsion through the surgical wound, observing the presence of iris tissue in the subconjunctival space next to the scleral cataract incision site. However, our UBM images, revealing a band of echogenic particles at the level of the anatomic iris position (Figure 1, D and E), cannot definitely rule out the sec- Figure 1. A, Slit lamp image, obtained on the fourth day after the trauma (soon after hyphema reabsorption), showing complete aniridia and an intact capsular bag with a stable IOL. B, Slit lamp image documenting a Tyndall phenomenon of greater than 3 (ie, visibility of small particles in liquid illuminated at a 90° angle) in the anterior chamber, also secondary to the dispersed hyphema. C, Gonioscopic views of the ciliary processes partially masked by the presence of remaining hemorrhage, the posterior chamber containing the inferior IOL haptic inside the capsular bag, and diffuse and slight particulate scattering. D, (facing page) Ultrasound biomicroscopic image, obtained on the fourth day after the trauma, showing the iridocorneal angle, a blood clot at the level of the iris root (arrow), a band of echogenic dots (corresponding to the Tyndall phenomenon shown in B), and the capsular bag. E, (facing page) Ultrasound biomicroscopic image of the ciliary processes. In the anterior chamber, the echogenic band (arrow) described in D is also evident. These UBM images (D and E) clearly detail the anterior chamber (ac), ciliary body (cb), ciliary processes (cp), cornea (c), haptic of the IOL (h), iris root (ir), optic of the IOL (o), posterior chamber (pc), and sclera (s). 1796 J Ultrasound Med 2007; 26:1795–1797 Parmeggiani et al ond deduction. This intriguing possibility has also been indirectly suggested by Ball et al3 as well as speculatively supported by several findings observed in experimental models of phagocytosis.6,7 In fact, the phagocytic properties of both macrophages and trabecular meshwork cells could theoretically explain the missing disinserted iris, which, even partially or totally remaining within the eye, should be identified as nonself material. J Ultrasound Med 2007; 26:1795–1797 References 1. Navon SE. Expulsive iridodialysis: an isolated injury after phacoemulsification. J Cataract Refract Surg 1997; 23: 805–807. 2. Lim JI, Nahl A, Johnston R, Jarus G. Traumatic total iridectomy due to iris extrusion through a self-sealing cataract incision. Arch Ophthalmol 1999; 117:542–543. 3. Ball J, Caesar R, Choudhuri D. Mystery of the vanishing iris. J Cataract Refract Surg 2002; 28:180–181. 4. Walker NJ, Foster A, Apel AJ. Traumatic expulsive iridodialysis after small-incision sutureless cataract surgery. J Cataract Refract Surg 2004; 30:2223–2224. 5. Lee SJ. Traumatic aniridia and aphakia after Artisan intraocular lens implantation. J Cataract Refract Surg 2007; 33: 1341–1342. 6. Sherwood ME, Richardson TM. Phagocytosis by trabecular meshwork cells: sequence of events in cats and monkeys. Exp Eye Res 1988; 46:881–895. 7. Reyer RW. Macrophage invasion and phagocytic activity during lens regeneration from the iris epithelium in newts. Am J Anat 1990; 188:329–344. 1797