Spontaneous late-onset pupillary block in a pseudophakic, vitrectomized eye despite prior Nd:YAG capsulotomy: a...

To report a rare case of spontaneous, delayed-onset pupillary block in a pseudophakic, vitrectomized eye with a prior Nd: YAG posterior capsulotomy, and to emphasize the importance of maintaining a high index of suspicion even in anatomically protected eyes.

We describe the clinical presentation, imaging findings, differential diagnosis, and management of a 78-year-old female with well-controlled primary open-angle glaucoma who presented with acute angle-closure symptoms in a previously vitrectomized, pseudophakic eye. Multimodal imaging, including anterior segment optical coherence tomography (OCT) and ultrasound biomicroscopy (UBM), was utilized to rule out malignant glaucoma and aqueous misdirection.

Slit-lamp examination revealed iris bombe and appositional angle closure in the left eye. Anterior segment OCT confirmed a shallow anterior chamber, while UBM excluded ciliochoroidal effusion and anterior rotation of the ciliary body. A diagnosis of acute pupillary block was established. Nd: YAG laser peripheral iridotomy (LPI) resulted in immediate resolution of symptoms and normalization of intraocular pressure.

Although pupillary block is generally considered unlikely in pseudophakic and vitrectomized eyes, this case demonstrates that it may still occur despite prior Nd:YAG posterior capsulotomy. Progressive anatomical changes may contribute to delayed obstruction of aqueous flow. Careful clinical examination, combined with anterior segment OCT and UBM, is essential for distinguishing pupillary block from other causes of secondary angle closure, particularly malignant glaucoma and aqueous misdirection.

This case demonstrates that pupillary block can occur spontaneously even in eyes with prior vitrectomy and YAG capsulotomy. Progressive anatomical changes may lead to delayed iris-lens apposition. Early diagnosis and treatment with LPI can reverse the condition and preserve vision. Clinicians should consider pupillary block in the differential diagnosis of acute angle closure, regardless of prior surgical history.