Common cases: Anterior Chamber and Iris

1. Dr. Riyad BanayotDr. Riyad Banayot

2.  Anterior Chamber
 Iris
 Glaucoma
 Lens

3.  Depth
 Cells and flare
 Foreign bodies (Molteno's tube and
silicone oil and less commonly heavy
liquid)

4.  The anterior chamber should be
examined for depth if you suspect the
anterior chamber is shallow especially if
there were signs of previous acute angle
closure glaucoma
 The angle is assessed by the Van Herick's
method

5.  Depth of peripheral anterior chamber (PAC)
compared to the adjacent corneal thickness (CT)
at temporal corneal limbus at 60° angle
 The technique uses the following set-up:
 Optical section
 60° between observation and illumination
 Full slit length
 Magnification approximately x 15
 Low to medium illumination
 Place optical section just inside limbus.
 Assuming the corneal thickness = 1 unit, assess the
width of the "aqueous gap" or peripheral anterior
chamber from corneal endothelium to iris

6. GradeRatio of aqueous gap/cornea Clinical
interpretation
4 > 1/2 : 1 Closure impossible
3 = 1/2 - 1/4 : 1 Closure impossible
2 = 1/4 : 1 Closure possible
1 < 1/4:1 Closure likely with full
dilatation
0 nil Closed

7. Mutton fat keratic precipitates Fine stellate keratic precipitates in
Fuch's heterochromic cyclitis
Cells and flare are common signs in uveitis

8. Koeppe nodules at the pupil margin Busacca nodule
Both conditions are indicative of granulamatous inflammation

9. Molteno's tube is usually
associated with the
following signs:
Previous trabeculectomy
(very often there are more than
one trabeculectomy with several
iridectomies)
Neovascular glaucoma
Iridocorneal endothelial
syndrome
Advanced glaucomatous
disc
If the tube is short, it may not be apparent
unless you get the patient to look down

10. Emulsified silicone oil in the anterior
chamber (hyperoleon)
Globules of heavy liquid in inferior
anterior chamber
Examine the posterior segment for the presence of previous retinal detachment,
proliferative vitreoretinopathy and advanced proliferative diabetic retinopathy

11.  The superior anterior
chamber contains fine
suspension of silicone oil.
 The oil may appear milky
owing to emulsification
(so-called inverted
hypopyon).
 Look for:
 Complications associated
with the oil (i.e. band
keratopathy and
cataract)
 Presence of Anton's
iridotomy (this is
iridectomy performed at
6 O'clock in aphakic
patient to prevent
pupillary block)
 Previous retinal

12.  Internal tamponade in giant retinal tears,
complex or traumatic retinal detachments
 Closure of breaks which are complicated
by proliferative diabetic retinopathy or
proliferative vitreo-retinopathy
 Dissection of epiretinal membranes and
flattening of the retina

14. Midperipheral iris transillumination in pigment dispersion syndrome

15. Diffuse iris transillumination in albinism

16. Sectoral iris transillumination in herpes zoster iritis. The feature results from iris
vasculitis. Note: the transillumination can also be diffuse if the involvement is extensive

17. Sectoral iris transillumination in a patient with iris prolapse during phaco.
Note the area involved corresponds to the corneal incision site for the phaco.

18. Diffuse mild iris transillumination in a patient with senile iris trophy

19.  The iris tissue is absent
inferonasally so that the
margin of the lens is
visible inferiorly (there may
be coloboma of
the lens or inferior cataract).
 The condition is usually
bilateral. There may be
microphthalmos.
 Examine the fundus
(fundi) for extension of
the coloboma
which may involve the
choroid and the optic disc
 The patient may have
esotropia (or rarely
exotropia) if the coloboma
involves the macular area
Iris Coloboma

20. Coloboma of the choroid and optic disc

21.  CHARGE syndrome in which there is
coloboma, heart defects, choanal atresia,
retarded growth, genital abnormalities
and ear anomalies.
 Merckerl-Gruber's syndrome in which
there are microcephaly, occipital
encephalocele, congenital heart defects,
polydactly, facial clefts and polycystic
renal and hepatic diseases.
 Sjogren-Larsson's syndrome with
microphthalmos and mental retardation.

22.  is a common physical sign in SL examination.
 Unless you perform retro-illumination, the sign
may be missed.
 The distribution of the transillumination can give
clue to the underlying cause.
 Common types:
 Peripapillary: Pseudoexfoliation syndrome
 Mid-periphery: Pigment dispersion syndrome
 Diffuse: albinism, previous acute angle closure glaucoma,
Fuchs' heterochromic cyclitis, senile iris atrophy, post-
cataract extraction
 Sectoral
 Herpes zoster iritis (look for scars on the forehead from
previous ophthalmic shingles)
 Iris prolapse during Phacoemulsification (this is usually at the
clock hour corresponding to the entry site)

23.  There is a pigmented lesion
on the iris (describe the
color, the edge, is it
flat/elevated.
 Look for signs of malignancy
(e.g. abnormal iris vessels
around or within the tumor,
ectopia uvea and sectoral
cataract at the site of the
lesion.
 Examine the posterior
segment for any extension;
alternatively, the iris lesion
(especially if it
is at the angle) may be an
extension from a lesion
behind the iris
 look at the sclera on the
side of the lesion for any
dilated vessels (sentinel
vessels) indicating that
there may be a lesion at the
ciliary body with anterior
extension
iris naevus
Ectopia uvea

24.  There is a pigmented lesion on
the iris (describe the color, the
edge, is it flat/elevated.
 Look for signs of malignancy
(e.g. abnormal iris vessels
around or within the tumor,
ectopia uvea and sectoral
cataract at the site of the
lesion.
 Examine the posterior
segment for any extension;
alternatively, the iris lesion
(especially if it
is at the angle) may be an
extension from a lesion behind
the iris
 look at the sclera on the side
of the lesion for any dilated
vessels (sentinel vessels)
indicating that there may be
a lesion at the ciliary body with
anterior extension
Iris melanoma with
intrinsic blood vessels

25.  Iris naevus / melanoma
 Primary iris cyst (Epithelial cyst arises secondary to splitting of the
posterior epithelial layers of the iris. Stromal cysts are found early in life,
appears as an unilateral, non-pigmented, thin walled lesions with few blood
vessels and stretches over the anterior surface)
 Secondary cysts (post surgical or trauma, frequently enlarge and lead to
serous complications such as glaucoma and inflammation
 Iris foreign body
 Lymphoma or leukemia
 Uveitis with granulomatous diseases such as TB, syphilis or sarcoidosis
 Lisch nodules in neurofibromatosis
 Juvenile xanthogranuloma. Appears as an orange-tan nodular or
sessile segmental thickening of the iris. Seen during early years of life,
regress spontaneously with steroid treatment, radiation therapy and rarely
iridectomy is required. Diagnosis: look for cutaneous manifestations and to
perform biopsy on the skin lesions (Touton's giant cells)
 Leiomyoma of the iris (from the deeper layers of the iris at the zone of
the sphincter muscle. An uncommon condition and usually appears diffuse
and flat with a predilection for the pupillary region of the iris)
 Vascular lesion of the iris such as haemangioma
 Metastatic lesion

26. Lisch nodules in neurofibromatosis

27.  The main diagnosis is between iris naevus and
iris melanoma.
 Lesion suggestive of melanoma include ectopia
uveae, intrinsic vessels, sectoral lens opacity,
glaucoma, uveitis and rapid growth.
 In the majority of cases, the lesion is observed
for growth with regular photographic
monitoring.
 If the lesion enlarges rapidly, iridectomy
(where only iris is involved) or iridocyclectomy
(if the angle is involved) may be performed
 95% life expectancy for iris melanoma
following surgical excision

28.  The iris is completely
absent or rudimentary.
The edges of the lens are
clearly visible. There may
be cataract with or
without subluxation. The
cornea may contain
pannus and dermoid.
 Patients C/O photophobia
and has nystagmus
(usually pendular ).
 Examine the fundus for
macular hypoplasia or
glaucomatous disc
changes.
 Examine the flank for
nephrectomy scar for
Wilm's tumour (Miller's
syndrome).
Aniridia

29. Aniridia Normal eye

30.  Deletion of the short arm of chromosome
11 in aniridia is associated with systemic
features including Wilm's tumour, mental
retardation and GU abnormalities.
 Not all aniridia has deletion of
chromosome 11.
 The inheritance of aniridia may be
autosomal dominant, autosomal
recessive or sporadic.

31.  In aniridia, the rudimentary iris becomes
attached to the trabecular meshwork as
the patients grows.
 This lead to impaired aqueous drainage.
 Glaucoma is uncommon at birth.

32. Heterochromia iridis

33.  Test the patient's VA and pupil response (in
siderosis bulbi the darker eye has poor vision
and the pupil is usually dilated and does not
react to light).
 Look for siderosis bulbi in which there are
usually signs of penetrating injury or Fuchs'
heterochromic iridis)
 Look for any signs of mild ptosis or anisocoria on
the side of the lighter iris for congenital Horner's
syndrome
 Examine the eye for any retained foreign body or
signs of previous penetrating injury.
 The optic disc may show glaucomatous damage.
 Look for diffuse keratitic precipitate, flare and
posterior subcapsular cataract in Fuchs‘
heterochromic iridis.

34.  Congenital: can be hypo or hyperchromic
 Causes of hyperchromic iris:
 Iris naevus
 Drug-induced as in unilateral use of
Latanoprost
 Rubeotic iridis
 Siderosis bulbi
 Causes of hypochromic iris:
 Chronic inflammation such as Fuchs'
heterochromic cyclitis
 Congenital Horner's syndrome
 Trauma

35.  Iris heterochromia
 Pupil dilatation and poor reaction to light
 Cataract
 Brown deposits on the anterior lens
 Vitreous opacities
 Peripheral retinal pigmentation which eventually
progresses to diffuse retinal pigmentation
 Narrowed retinal vessels
 Optic disc atrophy
 Secondary glaucoma due to accumulation of
iron in the trabecular meshwork

36.  Initially shows an increased a-wave and
normal b-wave.
 With time, the amplitude of b-wave
decreases.
 Eventually, the ERG becomes
extinguished.

37. A patient with
left-sided
siderosis bulbi.
Note the dark iris
and dilated pupil.
Heterochromic
iridis in a patient
with congenital
Horner's
syndrome. Note
the
miosis and mild
ptosis on the side
with lighter iris

38.  The patient has
blond hair and
poliosis
(oculocutaneous
albinism ).
 There may be
obvious nystagmus
(usually pendular)
and convergent
strabismus.
 The iris shows
transillumination.

39.  Fundal examination
may reveal macular
hypoplasia (shown by
absent foveal reflex).
 The temporal arcade
of the retinal vessels
run almost
horizontally.
 The retina is
hypopigmented (lack
of RPE pigment)
making the choroidal
vasculature easily
visible

40.  Ocular albinism is usually X-linked
recessive (also known as Nettleship-Falls
type)
 Oculo-cutaneous albinism is commonly
autosomal recessive.

41.  Patients who can produce pigmentation
have a less severe visual impairment than
those who cannot produce any
pigmentation.
 This can be determined using the hair
bulb test (in patients over the age of 4).
In this test, the hair bulb is incubated in a
solution containing tyrosine. In patients
who are tyrosinase-positive, pigmentation
of the hair occurs which is absent in
patients who are tyrosinase-negative.

42.  In albinism there is complete decussation
of the visual pathway.
Therefore, monocular stimulation of the
retina will only give cortical signal on
the contralateral cortex.

43.  Life expectancy is usually normal.
 But, some forms of albinism are
associated with life threatening
conditions.
 The two best known are:
 Chédiak-Higashi's syndrome (easy
susceptibility to recurrent infection due to
abnormal immunity)
 Hermansky-Pudlak's syndrome (easy
susceptibility to bruising and bleeding)