These synechiae are adhesions of the iris to the anterior lens capsule and in this case, they are due to prior trauma. This patient sustained blunt force trauma to the eye about a year ago and had a prolonged bout of inflammation afterwards. That resolved with topical steroid treatment but then a cataract developed in the ensuing months. The picture here shows the maximum pharmacologic dilation and we can see extensive areas of synechiae which are preventing mydriasis. The key to performing effective synechiolysis is to make two paracenteses incisions on opposite sites of the cornea. This will allow 360 degree access to the anterior chamber to lyse the synechiae. I use a 27g blunt cannula with a 3cc syringe filled with 0.5% lidocaine (made using a 50:50 ratio of preservative-free lidocaine 1% and balanced salt solution). A small amount is injected to keep the AC formed as the synechiae are lysed. I then use Dr Osher’s technique of visco-mydriasis where the viscoelastic is used to expand the pupil.
click to learn from this video about synechiolysis in a traumatic cataract case: