Tackling the Triple Trouble: Operated Trabeculectomy, Miotic Non-dilating Pupil, and Hard Brown Cataract

Surgical means of treating uncontrolled intraocular pressure are many, but trabeculectomy is still considered to be the gold standard. In a standard trabeculectomy surgery, a broad peripheral iridectomy is done as per standard teaching to prevent the iris from blocking the sclerostomy. We report an uncommon case of a 72-year-old lady who presented with complaints of decreased vision in the left eye with a history of bilateral trabeculectomy done for 20 years. She had no documents to substantiate the reason for performing the trabeculectomies nor any data on her previous clinical history and findings. Our examination revealed that the left eye had a superior bleb with no peripheral iridectomy and seclusio pupillae with grade IV hard cataract. There was a similar bleb in the right eye also. Due to her compromised vision, and our inability to visualize the fundus, she was taken up for ocular surgery. She underwent cataract surgery during which many challenges were faced and managed appropriately. Postoperatively, her aided vision was 6/9 p, and her IOP was 13 mmHg. The fundus showed healthy optic discs. This case raised many questions and dilemmas: the reason for the absence of iridectomies done with trabeculectomy and the cause of non-dilating pupil whether age related or due to posterior synechiae or seclusio pupillae. The case also highlights postoperative management of trabeculectomy with an adequate amount and duration of steroids and mydriatic eye drops which, if not followed, can result in inflammation and its sequelae. Every possible complication that may occur in tackling these complicated cases should be kept in mind, and correct instruments and medications should be readily available at the time of surgery.