A 60-year-old man presented with progressive visual deterior
A 60-year-old man presented with progressive visual deterioration over the previous few days, 3 years after uneventful bilateral phacoemulsification cataract extraction and subsequent insertion of an intraocular lens (IOL) in the bag, which was performed in another hospital. The patient reported a history of blunt trauma by a tennis ball to his left eye prior to cataract surgery. Otherwise, no ocular comorbidities were found, and the only systemic disease is known as arterial hypertension.

Corrected distance visual acuity (CDVA) decreased from 20/15 to counting fingers in the left eye. The IOL was found to be decentered and tilted, with an open posterior capsule, zonulolysis, and one haptic being displaced outside the capsular bag. Consequently, the IOL and capsular bag were removed, followed by anterior vitrectomy and implantation of a 3-piece IOL using scleral fixation with the Yamane technique.5 Because the IOL was not cut, a 6.0 mm superior limbal incision was made and, afterward, secured with 3 10-0 nylon interrupted sutures. When the patient was seen 4 days postoperatively, CDVA was 20/20 (+0.5+1.0×25), and 1 loose corneal suture was removed. Three weeks postoperatively, CDVA remained the same; however, an increase in astigmatism (−3.0+3.0×35) was noticed. A secondary corneal suture was placed on the flattest corneal meridian. Performed twice, the astigmatism was partly corrected, and all the sutures could be removed 2 months postoperatively with a consistent CDVA of 20/20 (−1.75+1.75×20) and intraocular pressure (IOP) of 14 mm Hg.

However, the patient returned 2 days later, complaining about the severe loss of vision, and slit-lamp examination revealed a total hyphema, referred to as 8-ball hyphema, because of its appearance when filling out the entire anterior chamber (AC). There was no pain, and the patient denied any kind of trauma. At follow-up appointments during the next few days, no subsiding of the hyphema was noted, and an ultrasound B-scan showed vitreous hemorrhage whereas the retina was intact and flat. IOP in the affected eye ranged from 24 to 34 mm Hg; thus, antiglaucomatous therapy was initiated (timolol 0.5%, 2 times a day, brimonidine, 2 times a day, and acetazolamide 125 mg, 2 times a day).

The patient was scheduled for surgery 1 week after the initial occurrence of the hyphema to remove the blood from the anterior and posterior segments through AC irrigation and pars plana vitrectomy. When aspirating the blood from the AC by bimanual irrigation/aspiration, an abnormality, which was initially considered to be an extremely dilated pupil, became visible. It became quite clear that the iris was missing. The retina was fully attached, and a small suspicious area surrounded by retinal hemorrhage was prophylactically treated by laser photocoagulation. The globe appeared intact, and no definite origin of the hemorrhage could be identified. Postoperative treatment consisted of bromfenac 2 times a day for 6 weeks, ofloxacin 3 times a day for 5 days, and prednisolone 10 mg/mL 4 times a day tapered over 1 month. A routine blood test, implemented on the day of surgery, showed anemia, thrombocytopenia, and elevated liver enzymes; hence, further workup was recommended.

Postoperatively, the most remarkable finding was a complete absence of iris tissue. No trace of iris could be detected in the AC, vitreous cavity, or subconjunctival area, and total aniridia with visible ciliary processes was confirmed on gonioscopy. The incision site was well adapted with no pigment entrapped within the wound. During subsequent follow-up visits, the IOL was centered, the retina attached, and vision was restored in the affected eye (CDVA: 20/20 with −0.25 sph), but the patient was disturbed by halos and glare. After 2 months, when IOP stabilized within normal levels and intraocular inflammation subsided, an artificial iris was implanted to reduce the patient's photophobia (HumanOptics AG). The patient is still on antiglaucomatous therapy to control his IOP, whereas he is no longer affected by halos or glare.

Source:https://journals.lww.com/jcro/Fulltext/2021/07000/The_8_ball_surprise.2.aspx
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