Why is the pupil peaked during this cataract surgery?

The iris is a fluid tissue that moves within the eye in response to the fluidic changes of cataract surgery. When we see a peaked pupil as a result of the iris tissue being pulled, it is a sign that something is not right. This cataract surgery is routine and it is going well without complications and then the peaked pupil is noticed. Why? What is going on?

The peaked pupil can be seen in cases of floppy iris syndrome where the hyper-mobile iris prolapses towards a leaky incision. But this patient has never taken Flomax (tamsulosin) or other agents which have been implicated in IFIS (intra-operative floppy iris syndrome).

Sometimes patients can have odd tissues that behave a bit differently, but this patient had surgery in the other eye without any iris issues and without a peaked pupil.

A run-out capsulorhexis with an anterior capsular tag can also cause the peaked pupil appearance during surgery, but this patient has a round and intact capsulorhexis.

And of course, vitreous prolapse can certainly cause a peaked pupil in cases of a posterior capsule rupture or focal zonular loss. I won’t give away the mystery — if you want to know the cause, watch the video!

Click below to see what is causing this peaked pupil and how I fixed the issue:

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