The most common symptoms of iris defects are glare and photophobia. Other symptoms can be multiplopia, reduced visual acuity, and reduced contrast sensitivity. Others may be conscious of the cosmetic disfigurement of their eye. The nonsurgical management of aniridia includes tinted glasses, occluder patches, tinted contact lenses, and artificial pupil contact lenses. For most patients, nonsurgical management is unsatisfactory. These patients may present later for surgical evaluation after years of failed nonsurgical management.
Repair strategies are largely guided by the extent of iris lost or damaged and the health of the remaining tissue. Patients can often tolerate defects covered by the upper eyelid with respect to glare and appearance, but sometimes, the superior tear meniscus contributes a prismatic effect that can make even small iridotomies symptomatic.[1] Sutures can often be used to repair small defects of the iris such as coloboma, iridodialysis, and mydriatic pupils.
Case 1
A 50 years old male patient presented with post-traumatic subluxated cataract (9 clock hours) with large iridodialysis (four clock hours). A conjunctival peritomy was done at the site of planned repair followed by cauterization of bleeder vessels. After placing a mark at 1.5 mm from limbus on the sclera, a partial thickness scleral flap was dissected with a crescent blade. Intra capsular cataract extraction (ICCE) was performed using a wire vectis. Vitrectomy was performed and main wound was closed using a 10’ nylon suture. A stab incision was created opposite to the site of iridodialysis using a MVR blade. A 26-gauge needle was inserted into the anterior chamber (AC) 1.5 mm behind the limbus. A Sinskey hook was inserted through a paracentesis site 5 clock hours from this point. The Sinskey hook provides counter pressure while the 26-gauge needle is passed through the iris root. One end of a double-armed 9-0 polypropylene suture is then pushed into the AC through the paracentesis port, and the suture needle is passed through the 26-gauge needle bevel. The 26-gauge needle is withdrawn from the eye, bringing the suture with it. The process is repeated with the second arm of the suture. The suture ends are tied outside, and conjunctiva is closed while the iris hangs in the desired position. On post-operative period the patient has a well-centered pupil with no AC reaction.
Case 2
A 59 years old male presents after complicated cataract surgery with decreased vision and glare. On examination, aphakia and loss of iris tissue is observed. Pilocarpine was injected through the main wound (2.2 mm incision) placed temporally. A stab incision was made opposite to the main wound incision. A 26 G needle is passed into the AC through the stab incision. It is passed through both ends of iris with the help of a 20 G pick forceps that provides counter-pressure. Similarly needle is passed through other end of the iris tissue. One end of a double-armed 9-0 polypropylene suture is then pushed into the AC through the paracentesis port, and the suture needle is passed through the 26-gauge needle bevel. The 26-gauge needle is withdrawn from the eye, bringing the suture with it. A Sinskey hook was used to engage the suture between the distal iris and the site where it exits the cornea. It was then withdrawn, retrieving a loop of suture through the incision. The externalized suture loop was oriented adjacent to the original strand, untwisting any polypropylene within the incision neck so as to achieve a parallel orientation of the sutures. The trailing end of the suture was passed down through the loop twice, always directing the passes back toward the cornea and then over itself. Each free end of the polypropylene suture was cinched, gently drawing the two iris surfaces together with the initial slipknot. The distal suture loop was again retrieved and externalized. The trailing end was passed up through the similarly oriented loop and under itself. The free suture ends were cinched gently, completing the locking knot. The ends of the suture were trimmed and removed with a 20-G horizontal scissors. The whole procedure was repeated to pass another slipknot. ACIOL implantation was then performed under air. Postoperatively the patient had a well-centered pupil with stable ACIOL.
Case 3
A 35 years old male presented after blunt trauma with cataract and sphincter tear along with mydriasis. Capsulorhexis was initiated using a bent needle. It was then completed using a capsulorhexis forceps. Lens aspiration was performed followed by insertion of PCIOL. A Sinskey hook was used to mobilize the iris prior to suturing to 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 straight needles was used. A 20-G pick forceps was used to provide counter traction to the iris for the passage of straight needles. After taking bites of iris at 8 and 4 o’clock, the 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. Several centimeters of suture were pulled through the AC. A pick forceps was used to engage the suture between the distal iris and the site where it exits the cornea. It was then withdrawn, retrieving a loop of suture through the incision. The externalized suture loop was oriented adjacent to the original strand, untwisting any polypropylene within the incision neck so as to achieve a parallel orientation of the sutures. The trailing end of the suture was passed down through the loop twice, always directing the passes back toward the cornea and then over itself. Each free end of the poly- propylene suture was cinched, gently drawing the 2 iris surfaces together with the initial slipknot. The distal suture loop was again retrieved and externalized. The trailing end was passed up through the similarly oriented loop and under itself. The free suture ends were cinched gently, completing the locking knot. The ends of the suture were trimmed and removed with a 20-G horizontal scissors. Postoperatively, there was a reduction of pupil size from 6.0×5.0 mm to 4 mm. The patient’s complaint of glare was relieved and the glare acuity was 20/40 at 6 months follow-up.
Discussion
The advantage of our technique in iridodialysis repair is the use of the limbus as a marker to obtain a precise scleral entry point. Another advantage is better control and ease of surgery because of the bimanual nature of our technique. We have achieved excellent results in all our cases with this technique. The use of a 26-gauge guide needle to pass a suture through the iris and sclera during an appositional repair has been described,[2] but it requires passing the 26-gauge needle out from within at a point opposite the iridodialysis site and entails blind scleral punctures. The Siepser slipknot was originally described for repairing iris defects through limbal incisions and later popularized by Chang for iris suturing of a posterior chamber IOL.[3,4] We have modified the Siepser slipknot to reduce the pupil size in a case of traumatic mydriasis. Our technique entailed a single passage of 10-0 polypropylene suture using a single suture, therefore obviating the main disadvantage of the Ogawa[5] technique, which requires multiple passes of suture. This technique may be useful in repair of traumatic mydriasis in cases where the pupil is oval; however, if pupil is circular and large, 2 such sutures may be required at opposing ends. In summary, these cases highlight the spectrum of cases with iris defects and their successful management. Suture repair of iris defects is a simple procedure, and offers good results in terms of relieving patients from the annoying complaints of glare and photophobia. Restoration of the iris is one of the most rewarding moments in anterior segment surgery.
