Retroiridian Pupilloplasty for Long-Standing Traumatic Pseudoacorea in a Phakic Eye: Surgical Technique

Retroiridian Pupilloplasty for Long-Standing Traumatic Pseudoacorea in a Phakic Eye: Surgical Technique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Retroiridian Pupilloplasty for Long-Standing Traumatic Pseudoacorea in a Phakic Eye: Surgical Technique Andres German Alza This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6941682/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We describe a novel surgical technique— retroiridian pupilloplasty —performed in a patient with traumatic pseudoacorea without cataract, presenting a 58-year history. Originally described by our group in 2022, the technique involves the creation of a neopupil posterior to the iris via peripheral iridectomy and the use of an anterior chamber vitrectome. In this case, the procedure resulted in significant improvements in both visual function and cosmetic appearance, required minimal postoperative follow-up, and allowed for rapid recovery. From the surgeon’s perspective, it was a straightforward, effective, and safe approach, representing a simple and viable therapeutic option for similar cases. Ophthalmology Pseudoacorea ocular trauma healthy lens phakic retroiridian pupilloplasty Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Pseudoacoria, or "hidden pupil," is a rare condition in which the pupil is not visible at rest and only becomes apparent after pharmacologic mydriasis. This distinguishes it from true acoria, where the pupil is completely absent. We present the case of a patient with traumatic pseudoacoria and an intact crystalline lens who was treated using an innovative surgical technique: phakic retroiridian pupilloplasty . Unlike conventional pupilloplasty techniques, this approach is performed through the retroiridian space (Fig. 1 ). Its effectiveness lies in its ability to anatomically restore the pupil while providing, to date, the simplest and most practical solution for this type of case. As the second case in our surgical series, it underscores both the feasibility and therapeutic potential of phakic retroiridian pupilloplasty for the treatment of pseudoacoria. Case Report We present the case of a 62-year-old male patient with acquired pseudoacoria in the right eye, resulting from blunt ocular trauma caused by a stone impact 58 years prior. Initially, visual acuity was limited to light perception. Slit-lamp biomicroscopy revealed pseudoacoria with an extensive superior corneal scar and endothelial involvement (Fig. 2 A–D). Evaluation with a Scheimpflug camera confirmed the apparent absence of a visible pupil (Fig. 3 A). To assess pupillary location and reactivity through the corneal opacity, near-infrared imaging was employed. This enabled the identification of a small, corectopic pupil displaced superiorly (Fig. 4 ). Based on these findings, phakic retroiridian pupilloplasty was selected as the surgical approach (Fig. 5 ). Postoperatively, the patient experienced a significant improvement in visual acuity, achieving a LogMAR of 0.22. Follow-up imaging with Scheimpflug camera (Fig. 2 B) confirmed the procedure’s success. A functional pupil with a sufficient diameter for refraction was obtained along with excellent residual visual acuity. These findings highlight the effectiveness of this technique in restoring visual function in cases of traumatic pseudoacoria with a preserved crystalline lens. Surgical Technique: The procedure began with local antisepsis and topical anesthesia. Two 0.8 mm sclero-corneal incisions were made (temporal and nasal), and one-third of the anterior chamber was filled with 2% hydroxypropyl methylcellulose to protect the endothelium. A peripheral iridectomy was then performed using Westcott scissors and Castroviejo forceps to access the retroiridian space. This retroiridian space was expanded by injecting 3% sodium hyaluronate, creating a dome that occupied two-thirds of the anterior chamber without contacting the endothelium. A 20G anterior vitrectome was introduced through the iridectomy and angled upward so that its silhouette was visible through the iris, avoiding contact with the crystalline lens. The phakic retroiridian pupilloplasty was performed using the following parameters: a cutting rate of 1000 cpm, aspiration rate of 20 cc/min, and vacuum pressure of 250 mmHg. At the end of the procedure, the viscoelastic was aspirated, the incisions were hydrated, and the iris was left engaged at the iridectomy site, eliminating the need for sutures. This resulted in the successful creation of a neopupil (Table 1 , Fig. 6A–J). Postoperative: The patient received topical treatment with combined ciprofloxacin 0.3% and dexamethasone 0.1% eye drops for 16 days. The initial dosage was four times daily for the first four days, reducing to twice daily for the remaining twelve days. Follow-up visits were scheduled at 24 hours, 5 days, and 1 month. Discussion The correction of pupillary abnormalities, regardless of their etiology, presents a significant surgical challenge, particularly in cases of pseudoacoria or acoria. Various approaches have traditionally been employed (Table 2 ), including Nd:YAG laser disruption ( 1 ), as well as the use of a vitrectome, microforceps, and microsurgical scissors ( 2 , 3 ). Among the techniques described, Kandori et al. proposed the use of a 25G vitrector for membrane removal. However, caution was taken to avoid damaging the anterior surface of the lens; therefore, the white membrane adherent to the lens was left in place ( 4 ). Another option is iris microendodiathermy or endothermal pupilloplasty ( 5 ), often combined with Siepser sutures ( 6 ) to reshape the pupil through tissue contraction induced by a bipolar cautery device. However, this latter method generates high temperatures, posing risks of damage to adjacent tissues, long-term iris depigmentation, and limited efficacy in cases of acoria. A common limitation shared by all these techniques is their anterior chamber approach, which increases the risk of accidental contact with the anterior lens capsule ( 7 , 8 ) and reduces intraoperative visibility. In this context, phakic retroiridian pupilloplasty emerges as an innovative surgical technique. Its goal is to create a new pupil in patients with pseudoacoria or a “hidden pupil,” while preserving the natural crystalline lens. Unlike conventional pupilloplasty techniques, this approach is performed through the retroiridian space ( 9 ), which offers a natural dissection plane, requires no additional instrumentation, and provides a distinct and potentially safer access route (Table 3 ). Our original method was first described in 2022 and was initially applied in a patient with pseudoacoria secondary to Axenfeld-Rieger syndrome ( 10 , 11 ). Subsequently, adaptations of our phakic technique have emerged. Specifically, the approach detailed by Bobrova et al. in 2025 integrates our entry method, dome formation, and retroiridian workspace strategy, supplemented by the use of a spatula, vitrectomy, and microsurgical scissors within the anterior chamber to excise a dense white membrane adherent to the iris, which caused acorea and anterior chamber obstruction ( 12 ). This second surgical case in our series, along with others employing our technique but with different etiologies than the one originally reported in 2022, further supports the feasibility and potential of phakic retroiridian pupilloplasty as an effective technique for correcting pseudoacoria. Conclusion Phakic retroiridian pupilloplasty is an innovative, effective, and safe surgical technique for the creation of a neopupil. It has been successfully performed in adult patients with both congenital and acquired pseudoacorea and may also will be considered in cases of acorea. With over three years of follow-up, this approach has demonstrated not only significant improvements in visual function and cosmetic outcomes but also promising potential in pediatric patients, where it could help prevent amblyopia and strabismus. These encouraging preliminary results warrant further validation through larger case series and long-term follow-up, positioning this technique as a significant advancement and a potentially more accessible and less invasive solution. Declarations ACKNOWLEDGEMENTS: To my father Dr. Enrique Alza, for teaching me this beautiful path of ophthalmology and for accompanying me on this journey in favor of science. Funding Information The author declares that he has not received financial support for the research from any governmental or private entity. Ethics Approval: Not applicable for that section. Patient Consent Statement : Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief. Availability of Data and Materials: The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request. Competing Interests : The author declares that they have no competing interests. Authors' Contributions: AGA were involved in the clinical follow-up of the patient, the data analysis and interpretation and drafted the manuscript. The author read and approved the end manuscript. References Gupta R, Kumar S, Sonika, Sood S. Laser and surgical management of hyperplastic persistent pupillary membrane. Ophthalmic Surg Lasers Imaging. 2003 Mar-Apr;34(2):136-9. PMID: 12665230. Ramasubramanian, Srikanth, and Parthopratim Dutta Majumder. Acorea: a rare congenital anomaly. Indian Journal of Ophthalmology 66.3 (2018): 450. Robb RM. Fibrous congenital iris membranes with pupillary distortion. Trans Am Ophthalmol Soc. 2001;99:45-50; discussion 50-1. PMID: 11797319; PMCID: PMC1359022. Kandori M, Saishin Y, Kusaka S, Shimojyo H, Otori Y, Tano Y. Pupilloplasty for congenital pupillary-iris-lens membrane with 25-gauge vitreous cutter. Acta Ophthalmol. 2010 Nov;88(7):e289-90. doi: 10.1111/j.1755-3768.2009.01698.x. PMID: 19860772. Xiang, W., Zhong, X., Chen, H., Chen, W., & Chen, W. (2019). Pupilloplasty by radiofrequency diathermy. Acta Ophthalmologica, 97(3), e479-e481. De Francesco T, Ma J, Ahmed IIK. Endothermal pupilloplasty to optimize pupil centration, size, and contour. J Cataract Refract Surg. 2021 Dec 1;47(12):e80-e83. doi: 10.1097/j.jcrs.0000000000000718. PMID: 34133402. Elhousseini, Z., Lee, E., & Williamson, T. H. (2016). Incidence of lens touch during pars plana vitrectomy and outcomes from subsequent cataract surgery. Retina, 36(4), 825-829. Alshabeeb, R. S., & Alharbi, S. S. (2019). Vitrector induced lens injury during peripheral iridectomy in implantable collamer lens surgery. Saudi Journal of Ophthalmology, 33(4), 389-391. Alza AG. Staining with trypan blue and retroiridian synechiolysis: effective approach in cataract surgery for patients with chronic uveitis, severe miosis, and posterior synechiae. Oftalmol Clin Exp 2024; 17(3): e464-e472. doi:10.70313/2718.7446.v17.n03.358 Alza, A. G., & Galletto, E. (2022). Retroiridian Pupilloplasty. Oftalmol Clin Exp (ISSN 1851-2658) 2022; 15(1): e40i-e47i. Alza, A. G. (2023). Case Report: Congenital Pseudoacorea in an Ocular Axenfeld-Rieger Syndrome: What is it?. J Clin Cases Rep. Author manuscript; available in PMC. Bobrova, N., Romanova, T., & Dovhan, O. (2025). Surgical pupil reconstruction for congenital idiopathic acorea with lens transparency saving. Case report. International Journal of Surgery Case Reports, 126, 110717. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6941682","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":474295414,"identity":"5f625399-fab7-4952-a5c6-d191a058c55f","order_by":0,"name":"Andres German Alza","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-8236-2958","institution":"Clínica Privada de Ojos Dr. Enrique Alza","correspondingAuthor":true,"prefix":"","firstName":"Andres","middleName":"German","lastName":"Alza","suffix":""}],"badges":[],"createdAt":"2025-06-20 22:11:11","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6941682/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6941682/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85368690,"identity":"6f14c420-5cd1-4ae8-9db8-350512330ddd","added_by":"auto","created_at":"2025-06-25 07:10:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":721115,"visible":true,"origin":"","legend":"\u003cp\u003eThis space is delimited by the posterior surface of the iris \u003cstrong\u003e(1)\u003c/strong\u003e, the ciliary sulcus \u003cstrong\u003e(2)\u003c/strong\u003e, the ciliary muscle \u003cstrong\u003e(3)\u003c/strong\u003e, the ciliary processes \u003cstrong\u003e(4)\u003c/strong\u003e, the anterior hyaloid membrane \u003cstrong\u003e(5)\u003c/strong\u003e, and the lens \u003cstrong\u003e(6)\u003c/strong\u003e. The pupil provides communication with the anterior chamber. Additional structures shown include Schlemm's canal \u003cstrong\u003e(7)\u003c/strong\u003e, the conjunctiva \u003cstrong\u003e(8)\u003c/strong\u003e, the sclera \u003cstrong\u003e(9)\u003c/strong\u003e, and the cornea \u003cstrong\u003e(10)\u003c/strong\u003e.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/d4998c70a29cc8163887d8ae.png"},{"id":85368691,"identity":"b3f20910-2564-424f-9fbd-2e2dc6634b79","added_by":"auto","created_at":"2025-06-25 07:10:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":484908,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA–D.\u003c/strong\u003e Slit-lamp photographs showing pseudoacoria, endothelial damage in the area of previous trauma, and a hidden pupil located behind a large superior corneal scar.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/2f7b84612781aec92bfe0bd5.png"},{"id":85369330,"identity":"a09e2e6c-2a70-4c03-a591-5a8cbe9a78f8","added_by":"auto","created_at":"2025-06-25 07:18:34","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":506846,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA.\u003c/strong\u003e Anterior segment evaluation using Scheimpflug imaging revealed the absence of a visible pupil. \u003cstrong\u003eB. \u003c/strong\u003eFollowing retroiridian pupilloplasty, a neopupil was observed.\u003c/p\u003e","description":"","filename":"image3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/c12504583a2b4253946e6332.jpg"},{"id":85368693,"identity":"5597ddff-acc4-469e-8ef2-09d9336d7eb0","added_by":"auto","created_at":"2025-06-25 07:10:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":537471,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of the pupillary response under infrared light spectrum in various lighting conditions, prior to pupilloplasty.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/c456e1313d732697f8eaa8ad.png"},{"id":85368696,"identity":"616f96be-2664-4c58-90b3-67232089cb65","added_by":"auto","created_at":"2025-06-25 07:10:34","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":722201,"visible":true,"origin":"","legend":"\u003cp\u003eSlit-lamp photographs following phakic retroiridian pupilloplasty.\u003c/p\u003e","description":"","filename":"image5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/c73417816b9abc07327108e3.jpg"},{"id":85369331,"identity":"eb8cbbfa-a398-4334-b821-3d64d6207b16","added_by":"auto","created_at":"2025-06-25 07:18:34","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":3353568,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA–J\u003c/strong\u003e. Sequential images illustrating the step-by-step technique of phakic retroiridian pupilloplasty. Two 0.8 mm sclero-corneal incisions were made at the temporal and nasal positions using a 15° blade (A–B). One-third of the anterior chamber was filled with 2% hydroxypropyl methylcellulose to protect the corneal endothelium (C). A peripheral iridectomy was performed using Westcott scissors and Castroviejo forceps to gain access to the retroiridian space (D). This space was then expanded with 3% sodium hyaluronate, forming a convex dome occupying two-thirds of the anterior chamber without contacting the endothelium (E). A 20-gauge anterior chamber vitrectome was introduced through the iridectomy; its silhouette was visualized through the iris to ensure avoidance of contact with the crystalline lens (F). Phakic retroiridian pupilloplasty was then performed (G). The viscoelastic material was aspirated from the anterior chamber (H). The incisions were hydrated, leaving the iris engaged at the site of the iridectomy (I). The final image shows the resulting neopupil (J).\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/74bd874606c7f80e3cbd240f.png"},{"id":85371085,"identity":"09665d1d-3700-4561-a3a1-736769277375","added_by":"auto","created_at":"2025-06-25 07:34:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8355142,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/a76f5f22-9968-48fc-9404-7a5147bb1ee2.pdf"},{"id":85368688,"identity":"3b75f262-3fb3-482f-8086-615cae548fb9","added_by":"auto","created_at":"2025-06-25 07:10:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19075,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6941682/v1/03e07399549566d8183eac1e.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eRetroiridian Pupilloplasty for Long-Standing Traumatic Pseudoacorea in a Phakic Eye: Surgical Technique\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePseudoacoria, or \"hidden pupil,\" is a rare condition in which the pupil is not visible at rest and only becomes apparent after pharmacologic mydriasis. This distinguishes it from true acoria, where the pupil is completely absent. We present the case of a patient with traumatic pseudoacoria and an intact crystalline lens who was treated using an innovative surgical technique: \u003cem\u003ephakic retroiridian pupilloplasty\u003c/em\u003e. Unlike conventional pupilloplasty techniques, this approach is performed through the retroiridian space (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Its effectiveness lies in its ability to anatomically restore the pupil while providing, to date, the simplest and most practical solution for this type of case. As the second case in our surgical series, it underscores both the feasibility and therapeutic potential of phakic retroiridian pupilloplasty for the treatment of pseudoacoria.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eWe present the case of a 62-year-old male patient with acquired pseudoacoria in the right eye, resulting from blunt ocular trauma caused by a stone impact 58 years prior. Initially, visual acuity was limited to light perception. Slit-lamp biomicroscopy revealed pseudoacoria with an extensive superior corneal scar and endothelial involvement (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA\u0026ndash;D). Evaluation with a Scheimpflug camera confirmed the apparent absence of a visible pupil (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). To assess pupillary location and reactivity through the corneal opacity, near-infrared imaging was employed. This enabled the identification of a small, corectopic pupil displaced superiorly (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Based on these findings, phakic retroiridian pupilloplasty was selected as the surgical approach (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Postoperatively, the patient experienced a significant improvement in visual acuity, achieving a LogMAR of 0.22. Follow-up imaging with Scheimpflug camera (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB) confirmed the procedure\u0026rsquo;s success.\u003c/p\u003e \u003cp\u003eA functional pupil with a sufficient diameter for refraction was obtained along with excellent residual visual acuity. These findings highlight the effectiveness of this technique in restoring visual function in cases of traumatic pseudoacoria with a preserved crystalline lens.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Technique:\u003c/h2\u003e \u003cp\u003eThe procedure began with local antisepsis and topical anesthesia. Two 0.8 mm sclero-corneal incisions were made (temporal and nasal), and one-third of the anterior chamber was filled with 2% hydroxypropyl methylcellulose to protect the endothelium. A peripheral iridectomy was then performed using Westcott scissors and Castroviejo forceps to access the retroiridian space. This retroiridian space was expanded by injecting 3% sodium hyaluronate, creating a dome that occupied two-thirds of the anterior chamber without contacting the endothelium. A 20G anterior vitrectome was introduced through the iridectomy and angled upward so that its silhouette was visible through the iris, avoiding contact with the crystalline lens. The phakic retroiridian pupilloplasty was performed using the following parameters: a cutting rate of 1000 cpm, aspiration rate of 20 cc/min, and vacuum pressure of 250 mmHg. At the end of the procedure, the viscoelastic was aspirated, the incisions were hydrated, and the iris was left engaged at the iridectomy site, eliminating the need for sutures. This resulted in the successful creation of a neopupil (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;6A\u0026ndash;J).\u003c/p\u003e \n\u003ch3\u003ePostoperative:\u003c/h3\u003e\n\u003cp\u003eThe patient received topical treatment with combined ciprofloxacin 0.3% and dexamethasone 0.1% eye drops for 16 days. The initial dosage was four times daily for the first four days, reducing to twice daily for the remaining twelve days. Follow-up visits were scheduled at 24 hours, 5 days, and 1 month.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe correction of pupillary abnormalities, regardless of their etiology, presents a significant surgical challenge, particularly in cases of pseudoacoria or acoria. Various approaches have traditionally been employed (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), including Nd:YAG laser disruption (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e), as well as the use of a vitrectome, microforceps, and microsurgical scissors (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Among the techniques described, Kandori et al. proposed the use of a 25G vitrector for membrane removal. However, caution was taken to avoid damaging the anterior surface of the lens; therefore, the white membrane adherent to the lens was left in place (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). Another option is iris microendodiathermy or endothermal pupilloplasty (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e), often combined with Siepser sutures (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e) to reshape the pupil through tissue contraction induced by a bipolar cautery device. However, this latter method generates high temperatures, posing risks of damage to adjacent tissues, long-term iris depigmentation, and limited efficacy in cases of acoria. A common limitation shared by all these techniques is their anterior chamber approach, which increases the risk of accidental contact with the anterior lens capsule (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e) and reduces intraoperative visibility. In this context, phakic retroiridian pupilloplasty emerges as an innovative surgical technique. Its goal is to create a new pupil in patients with pseudoacoria or a \u0026ldquo;hidden pupil,\u0026rdquo; while preserving the natural crystalline lens. Unlike conventional pupilloplasty techniques, this approach is performed through the retroiridian space (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e), which offers a natural dissection plane, requires no additional instrumentation, and provides a distinct and potentially safer access route (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Our original method was first described in 2022 and was initially applied in a patient with pseudoacoria secondary to Axenfeld-Rieger syndrome (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). Subsequently, adaptations of our phakic technique have emerged. Specifically, the approach detailed by Bobrova et al. in 2025 integrates our entry method, dome formation, and retroiridian workspace strategy, supplemented by the use of a spatula, vitrectomy, and microsurgical scissors within the anterior chamber to excise a dense white membrane adherent to the iris, which caused acorea and anterior chamber obstruction (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThis second surgical case in our series, along with others employing our technique but with different etiologies than the one originally reported in 2022, further supports the feasibility and potential of phakic retroiridian pupilloplasty as an effective technique for correcting pseudoacoria.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePhakic retroiridian pupilloplasty is an innovative, effective, and safe surgical technique for the creation of a neopupil. It has been successfully performed in adult patients with both congenital and acquired pseudoacorea and may also will be considered in cases of acorea. With over three years of follow-up, this approach has demonstrated not only significant improvements in visual function and cosmetic outcomes but also promising potential in pediatric patients, where it could help prevent amblyopia and strabismus. These encouraging preliminary results warrant further validation through larger case series and long-term follow-up, positioning this technique as a significant advancement and a potentially more accessible and less invasive solution.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo my father Dr. Enrique Alza, for teaching me this beautiful path of ophthalmology and for accompanying me on this journey in favor of science.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that he has not received financial support for the research from any governmental or private entity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable for that section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent Statement\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability\u003c/strong\u003e \u003cstrong\u003eof\u003c/strong\u003e \u003cstrong\u003eData and Materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003c/strong\u003e \u003cstrong\u003eInterests\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe author declares that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAGA were involved in the clinical follow-up of the patient, the data analysis and interpretation and drafted the manuscript. The author read and approved the end manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGupta R, Kumar S, Sonika, Sood S. Laser and surgical management of hyperplastic persistent pupillary membrane. Ophthalmic Surg Lasers Imaging. 2003 Mar-Apr;34(2):136-9. PMID: 12665230.\u003c/li\u003e\n \u003cli\u003eRamasubramanian, Srikanth, and Parthopratim Dutta Majumder. Acorea: a rare congenital anomaly. Indian Journal of Ophthalmology 66.3 (2018): 450.\u003c/li\u003e\n \u003cli\u003eRobb RM. Fibrous congenital iris membranes with pupillary distortion. Trans Am Ophthalmol Soc. 2001;99:45-50; discussion 50-1. PMID: 11797319; PMCID: PMC1359022.\u003c/li\u003e\n \u003cli\u003eKandori M, Saishin Y, Kusaka S, Shimojyo H, Otori Y, Tano Y. Pupilloplasty for congenital pupillary-iris-lens membrane with 25-gauge vitreous cutter. Acta Ophthalmol. 2010 Nov;88(7):e289-90. doi: 10.1111/j.1755-3768.2009.01698.x. PMID: 19860772.\u003c/li\u003e\n \u003cli\u003eXiang, W., Zhong, X., Chen, H., Chen, W., \u0026amp; Chen, W. (2019). Pupilloplasty by radiofrequency diathermy. Acta Ophthalmologica, 97(3), e479-e481.\u003c/li\u003e\n \u003cli\u003eDe Francesco T, Ma J, Ahmed IIK. Endothermal pupilloplasty to optimize pupil centration, size, and contour. J Cataract Refract Surg. 2021 Dec 1;47(12):e80-e83. doi: 10.1097/j.jcrs.0000000000000718. PMID: 34133402.\u003c/li\u003e\n \u003cli\u003eElhousseini, Z., Lee, E., \u0026amp; Williamson, T. H. (2016). Incidence of lens touch during pars plana vitrectomy and outcomes from subsequent cataract surgery. Retina, 36(4), 825-829.\u003c/li\u003e\n \u003cli\u003eAlshabeeb, R. S., \u0026amp; Alharbi, S. S. (2019). Vitrector induced lens injury during peripheral iridectomy in implantable collamer lens surgery. Saudi Journal of Ophthalmology, 33(4), 389-391.\u003c/li\u003e\n \u003cli\u003eAlza AG. Staining with trypan blue and retroiridian synechiolysis: effective approach in cataract surgery for patients with chronic uveitis, severe miosis, and posterior synechiae. Oftalmol Clin Exp 2024; 17(3): e464-e472. doi:10.70313/2718.7446.v17.n03.358\u003c/li\u003e\n \u003cli\u003eAlza, A. G., \u0026amp; Galletto, E. (2022). Retroiridian Pupilloplasty. Oftalmol Clin Exp (ISSN 1851-2658) 2022; 15(1): e40i-e47i.\u003c/li\u003e\n \u003cli\u003eAlza, A. G. (2023). Case Report: Congenital Pseudoacorea in an Ocular Axenfeld-Rieger Syndrome: What is it?. J Clin Cases Rep. Author manuscript; available in PMC.\u003c/li\u003e\n \u003cli\u003eBobrova, N., Romanova, T., \u0026amp; Dovhan, O. (2025). Surgical pupil reconstruction for congenital idiopathic acorea with lens transparency saving. Case report. International Journal of Surgery Case Reports, 126, 110717.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pseudoacorea, ocular trauma, healthy lens, phakic retroiridian pupilloplasty","lastPublishedDoi":"10.21203/rs.3.rs-6941682/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6941682/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe describe a novel surgical technique\u0026mdash;\u003cb\u003eretroiridian pupilloplasty\u003c/b\u003e\u0026mdash;performed in a patient with traumatic pseudoacorea without cataract, presenting a 58-year history. Originally described by our group in 2022, the technique involves the creation of a neopupil posterior to the iris via peripheral iridectomy and the use of an anterior chamber vitrectome. In this case, the procedure resulted in significant improvements in both visual function and cosmetic appearance, required minimal postoperative follow-up, and allowed for rapid recovery. From the surgeon\u0026rsquo;s perspective, it was a straightforward, effective, and safe approach, representing a simple and viable therapeutic option for similar cases.\u003c/p\u003e","manuscriptTitle":"Retroiridian Pupilloplasty for Long-Standing Traumatic Pseudoacorea in a Phakic Eye: Surgical Technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 07:10:29","doi":"10.21203/rs.3.rs-6941682/v1","editorialEvents":[{"type":"communityComments","content":3}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64e7434a-7183-4839-be73-875529af8c13","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50373284,"name":"Ophthalmology"}],"tags":[],"updatedAt":"2025-06-25T07:10:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-25 07:10:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6941682","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6941682","identity":"rs-6941682","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}