E-ISSN 0976-2892

Techniques

Repair of Iris Defects

Tushar Agarwal, Tarun Arora Purpose: To demonstrate three techniques of repair of iris defects in cases with iridodialysis, post
Cornea, Cataract and surgical coloboma and post-traumatic mydriasis.
Refractive Surgery Services Methods: Video-based description of repair of three cases of iris defects, highlighting the technique
Dr R P Centre AIIMS, and difficulties in performing surgery in these cases.
New Delhi, India
Results: In the first case with post-traumatic subluxated cataract and iridodialysis, ICCE and
iridodialysis repair was performed successfully. The second case had surgical coloboma and aphakia
*Address for correspondence
due to previous complicated cataract surgery. Repair of the coloboma and implantation of ACIOL
was performed successfully. Third case presented with a post-traumatic cataract and sphincter tear
associated with mydriasis. PCIOL implantation along with mydriasis repair was performed.
Conclusions: With the help of these techniques, sutures can be used to repair iridodialysis,
colobomatous defects, and mydriatic pupils. Results in these patients are very gratifying. Patients
appreciate the reduction in light and glare sensitivity in the immediate post-operative period
Tushar Agarwal MD Keywords : iridodialysis • traumatic mydriasis • coloboma
Cornea, Cataract and
Refractive Surgery Services The most common symptoms of iris bleeder vessels. After placing a mark at 1.5
Dr R P Centre AIIMS, defects are glare and photophobia. Other mm from limbus on the sclera, a partial
New Delhi, India symptoms can be multiplopia, reduced thickness scleral flap was dissected with
Email: drtushar@gmail.com visual acuity, and reduced contrast a crescent blade. Intra capsular cataract
sensitivity. Others may be conscious extraction (ICCE) was performed using a
of the cosmetic disfigurement of their wire vectis. Vitrectomy was performed and
eye. The nonsurgical management main wound was closed using a 10’ nylon
of aniridia includes tinted glasses, suture. A stab incision was created opposite
occluder patches, tinted contact lenses, to the site of iridodialysis using a MVR
and artificial pupil contact lenses. For blade. A 26-gauge needle was inserted into
most patients, nonsurgical management the anterior chamber (AC) 1.5 mm behind
is unsatisfactory. These patients may the limbus. A Sinskey hook was inserted
present later for surgical evaluation after through a paracentesis site 5 clock hours
years of failed nonsurgical management. from this point. The Sinskey hook provides
Repair strategies are largely guided counter pressure while the 26-gauge needle
by the extent of iris lost or damaged is passed through the iris root. One end of
and the health of the remaining tissue. a double-armed 9-0 polypropylene suture
Patients can often tolerate defects is then pushed into the AC through the
covered by the upper eyelid with respect paracentesis port, and the suture needle
to glare and appearance, but sometimes, is passed through the 26-gauge needle
the superior tear meniscus contributes a bevel. The 26-gauge needle is withdrawn
prismatic effect that can make even small from the eye, bringing the suture with it.
iridotomies symptomatic.1 Sutures can The process is repeated with the second
often be used to repair small defects of arm of the suture. The suture ends are tied
the iris such as coloboma, iridodialysis, outside, and conjunctiva is closed while the
iris hangs in the desired position. On post-
and mydriatic pupils.
operative period the patient has a well-
centered pupil with no AC reaction.
Case 1
A 50 years old male patient presented
with post-traumatic subluxated cataract Case 2
(9 clock hours) with large iridodialysis A 59 years old male presents after
(four clock hours). A conjunctival complicated cataract surgery with
peritomy was done at the site of planned decreased vision and glare. On examination,
repair followed by cauterization of aphakia and loss of iris tissue is observed.
Pilocarpine was injected through the main

Video on DJO web page 106

Techniques Agarwal T & Arora T

wound (2.2 mm incision) placed temporally. A stab incision suture loop was again retrieved and externalized. The
was made opposite to the main wound incision. A 26 G trailing end was passed up through the similarly oriented
needle is passed into the AC through the stab incision. It is loop and under itself. The free suture ends were cinched
passed through both ends of iris with the help of a 20 G pick gently, completing the locking knot. The ends of the suture
forceps that provides counter-pressure. Similarly needle is were trimmed and removed with a 20-G horizontal scissors.
passed through other end of the iris tissue. One end of a Postoperatively, there was a reduction of pupil size from
double-armed 9-0 polypropylene suture is then pushed into 6.0×5.0 mm to 4 mm. The patient’s complaint of glare was
the AC through the paracentesis port, and the suture needle relieved and the glare acuity was 20/40 at 6 months follow-
is passed through the 26-gauge needle bevel. The 26-gauge up.
needle is withdrawn from the eye, bringing the suture with
it. A Sinskey hook was used to engage the suture between Discussion
the distal iris and the site where it exits the cornea. It was The advantage of our technique in iridodialysis repair
then withdrawn, retrieving a loop of suture through the is the use of the limbus as a marker to obtain a precise scleral
incision. The externalized suture loop was oriented adjacent entry point. Another advantage is better control and ease of
to the original strand, untwisting any polypropylene within surgery because of the bimanual nature of our technique.
the incision neck so as to achieve a parallel orientation of We have achieved excellent results in all our cases with
the sutures. The trailing end of the suture was passed this technique. The use of a 26-gauge guide needle to pass
down through the loop twice, always directing the passes a suture through the iris and sclera during an appositional
back toward the cornea and then over itself. Each free end repair has been described,2 but it requires passing the
of the polypropylene suture was cinched, gently drawing 26-gauge needle out from within at a point opposite the
the two iris surfaces together with the initial slipknot. The iridodialysis site and entails blind scleral punctures. The
distal suture loop was again retrieved and externalized. Siepser slipknot was originally described for repairing iris
The trailing end was passed up through the similarly defects through limbal incisions and later popularized by
oriented loop and under itself. The free suture ends were Chang for iris suturing of a posterior chamber IOL.3,4 We have
cinched gently, completing the locking knot. The ends of the modified the Siepser slipknot to reduce the pupil size in a
suture were trimmed and removed with a 20-G horizontal case of traumatic mydriasis. Our technique entailed a single
scissors. The whole procedure was repeated to pass another passage of 10-0 polypropylene suture using a single suture,
slipknot. ACIOL implantation was then performed under therefore obviating the main disadvantage of the Ogawa5
air. Postoperatively the patient had a well-centered pupil technique, which requires multiple passes of suture. This
with stable ACIOL. technique may be useful in repair of traumatic mydriasis in
cases where the pupil is oval; however, if pupil is circular
Case 3 and large, 2 such sutures may be required at opposing ends.
A 35 years old male presented after blunt trauma In summary, these cases highlight the spectrum of cases with
with cataract and sphincter tear along with mydriasis. iris defects and their successful management. Suture repair
Capsulorhexis was initiated using a bent needle. It was then of iris defects is a simple procedure, and offers good results
completed using a capsulorhexis forceps. Lens aspiration in terms of relieving patients from the annoying complaints
was performed followed by insertion of PCIOL. A Sinskey of glare and photophobia. Restoration of the iris is one of
hook was used to mobilize the iris prior to suturing to the most rewarding moments in anterior segment surgery.
ensure there were no posterior synechiae. Two opposing
stab incisions were made using a 15-degree blade. A 10-0
polypropylene suture (6002 PP, Aurolab, India) with
Financial & competing interest disclosure
straight needles was used. A 20-G pick forceps was used to The authors do not have any competing interests in any product/
provide counter traction to the iris for the passage of straight procedure mentioned in this study. The authors do not have any financial
needles. After taking bites of iris at 8 and 4 o’clock, the interests in any product / procedure mentioned
needle was exited out of the AC with the help of 26-G guide
needle through the second side port at 4 o’clock position. References
Several centimeters of suture were pulled through the AC.
1. Spaeth GL, Idowu O, Seligsohn A, et al. The effects of
A pick forceps was used to engage the suture between the
iridotomy size and position on symptoms following laser
distal iris and the site where it exits the cornea. It was then peripheral iridotomy. J Glaucoma 2005; 14:5:364-7.
withdrawn, retrieving a loop of suture through the incision. 2. Bardak Y, Ozerturk Y, Durmus M, Mensiz E, Aytuluner E.
The externalized suture loop was oriented adjacent to the Closed chamber iridodialysis repair using a needle with a
original strand, untwisting any polypropylene within the distal hole. J Cataract Refract Surg 2000; 26:173–6
incision neck so as to achieve a parallel orientation of the 3. Siepser SB. The closed chamber slipping suture technique for
iris repair. Ann Ophthalmol 1994; 26:71-2.
sutures. The trailing end of the suture was passed down
4. Chang DF. Siepser slipknot for McCannel iris-suture fixation
through the loop twice, always directing the passes back of subluxated intraocular lenses. J Cataract Refract Surg 2004;
toward the cornea and then over itself. Each free end of the 30:1170-6.
poly- propylene suture was cinched, gently drawing the 5. Ogawa GSH. The iris cerclage suture for permanent mydriasis:
2 iris surfaces together with the initial slipknot. The distal a running suture technique. Ophthalmic Surg Lasers 1998;
29:1001-9.

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Video on DJO web page Del J Ophthalmol 2014;25(2)