Our reported case had an intumescent cataract with diffuse iris atrophy of the left eye in which the cataract removed and the residual iris reconstructed. The exact pathogenesis of HZO complications is not well understood, it could be due to viral replication in the early disease stages and the inflammation associated with that [2]. In HZO, the complications requiring surgical intervention are the Neuroparalytic ulcer, Glaucoma, Corneal scar and Cataract [3] in which the cataract is the most common one [1].

The common presentation is the posterior subcapsular cataract in which the steroid and chronic inflammation (uveitis) from virus play a role [2] in our case the patient was having an intumescent type of cataract which is not common in HZO and also its surgical management (phacoemulsification) is a bit difficult as compared to posterior sub-capsular cataract.

A retrospective study of 24 operated eyes of HZO patient having a cataract, the corrected distant visual acuity (CDVA) before surgery 20/112 after phacoemulsification + posterior capsular intraocular (PCIOL) the patient had CDVA 20/44 in the first year [1].  The choice of either ECCE or phacoemulsification and quince 6 months patient have better results on favorable long-term follow up (> 20y) the best-corrected visual acuity ( BCVA ) was 20/20 [2]. Another study done 11 eyes operated, the BCVA was 20/40 [1]. Most surgeons delay surgical intervention up to 3 months of quiescence and avoiding the active phase of the disease since the surgical intervention can trigger the disease [4]. Our patient had 6 months quiescence period since the last episode of uveitis.

Patients of HZO have the risk of complications after cataract surgery such as developing a corneal scar, fractional retinal detachment or recurrence of uveitis requiring further intervention [1]. Thus the adequate control of inflammation, intraocular pressure, and ocular surface disease improved the visual prognosis of cataract surgery of HZO patient [4], despite the advance of therapy HZO complication may be reduced but not eliminated [2]. Visual recovery compromised by the preexisting chronic ocular condition [1] thus it has an unpredictable result for cataract surgery.

Another situation we had in our patient which is rudimentary iris contour this may be due to chronic iritis and diffuse iris atrophy [3]. We were concern about cataract surgery results that may be compromised by the absence of iris coverage. Patient’s glare might worsen further causing more severe glare and photophobia due to reactivation of herpetic uveitis thus leading to unacceptable cosmetic appearance.

There are many techniques for pupilloplasty such Siper slipknot and the modified version, these options were on the table but using single-pass four-throw pupilloplasty technique provide a better option for our patient having advantages of minimal iris manipulation single pass, thus fewer iris pigment dispersion saving what we have of iris structure and also minimizing the reactivation of post-surgical induced uveitis [5]. This technique has an only single pass through the anterior chamber wherein 4 throws in helical configuration taken externally through the suture loop withdrawn from the anterior chamber, few steps were captured (Figure 2). Minimal iris manipulation single pass, thus fewer iris pigment dispersion saving what we have of iris structure [5] and also minimizing the reactivation of post-surgical induced uveitis. Although it has no true looking knot system, this technique provides a self-looking and self-retaining mechanism preventing the loop from reopening [6]. Single-pass four throw pupilloplasty provide adequate pupil dilatation after pupilloplasty facilitating retina examination if needed for patients of HZO. This technique achieves good pupil size, and contour [5].