Indian Journal of Clinical and Experimental Ophthalmology

Print ISSN: 2395-1443

Online ISSN: 2395-1451

CODEN : IJCEKF

Indian Journal of Clinical and Experimental Ophthalmology (IJCEO) is open access, a peer-reviewed medical journal, published quarterly, online, and in print, by the Innovative Education and Scientific Research Foundation (IESRF) since 2015. To fulfil our aim of rapid dissemination of knowledge, we publish articles ‘Ahead of Print’ on acceptance. In addition, the journal allows free access (Open Access) to its content, which is likely to attract more readers and citations of articles published in IJCEO. Manuscripts must be prepared in more...

  • Article highlights
  • Article tables
  • Article images

Article statistics

Viewed: 112

PDF Downloaded: 63


Get Permission Sekizhan, Gnaneswaran, Chokkalingam, and Murugesan: A simple suture technique to repair iatrogenic iridodialysis post cataract surgery: A case report


Introduction

Iridodialysis is a localized disinsertion of the iris from its attachment to the ciliary body where it is weakest and thinnest.1, 2 It generally occurs due to oculartrauma3 and intraocular procedures such as cataract surgery.4 The incidence of iridodialysis due to small incision cataract surgery stands at 0.2%.5 Intervention might not be required when the dialysis is small, but large and symptomatic iridodialysis frequentlyneeds surgical repair.Superior iridodialysis involving 10 O’ clock to 2 O’ clock positionis often less symptomatic as it is covered by the upper eye lid whereastemporal, inferior and large iridodialysis are usually symptomatic. Numerous techniques for iridodialysisrepair have been described, most of them being technically challenging.4, 6, 7 We describe a simplified approach of iridodialysis repair using 10-0 non absorbable monofilament polyamide suture (Ethilon)and basic instrumentsused for a conventional cataract surgerywith a favourable outcome.

Case Report

A 62 years old male was undergoing cataract surgery in his right eye by a trainee surgeon under the supervision of a senior surgeon. After nucleus delivery a large iridodialysis was noted inferiorly from 4 O’clock to 8 O’clock position- (Figure 1 A, B and Figure 2 A). As the dialysis was large and inferiorly situated, it was decided to repair the iris in the same sitting and planned after the implantation of intra ocular lens.

Figure 1

A): Pre-operative photograph showing an inferior iridodialysis from 4 O’clock to 8 O’clock position (shaded area) and prolapsed iris superiorly through the main wound. Note the D shaped pupil due to iridodialysis; B): Preoperative photograph after iris reposition

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/f19ce364-1d96-4185-9417-ab84dd8b0ee4/image/3a84c60a-89b2-4c46-bec7-12de14be7b3b-uimage.png

Figure 2

Step wise illustration of iridodialysis repair: A): Depiction of Iridodialysis and iris prolapse; B): Three sutures passed from sclera side (5 O’ clock, 6 O’ clock and 7 O’ clock positions) through the corresponding edges of iris and exteriorized through cornea; C): Sutures individually tied in 3-2-2 fashion and rotated inwards to approximate the iris to its insertion

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/f19ce364-1d96-4185-9417-ab84dd8b0ee4/image/8814a529-0542-4f2f-8a81-4386afd17073-uimage.png

Figure 3

Postoperative picture showing correction of iridodialysis and formation of fairly round pupil centrally

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/f19ce364-1d96-4185-9417-ab84dd8b0ee4/image/62c1443d-ffcb-4364-8277-83b5c52e8b0d-uimage.png

Surgical technique

Following a top up peribulbar anaesthesia, inferior peritomy was done and hemostasis attained with light cautery. A 10-0 non absorbable monofilament polyamide suture (Ethilon) with a curved needle was passed from sclera at 7 O’clock position corresponding to the iris insertion, the inferior edge of the detached iris is taken into the needle with the help of an iris repositor in the anterior chamber and the suture is exteriorized through cornea. The same as above was done at 6 O’ clock and 5 O’ clock positions as shown in Figure 2 B. The three sutures were tied with knots in 3-2-2 fashion. All the knots were rotated into the anterior chamber and pulled towards the angle of anterior chamber so that the knots approximated the edges of the dialysed iris to its insertion as shown in Figure 1 C. The procedure was completed with formation of anterior chamber with balanced salt solution and air followed by closure of peritomy and placement of a bandage contact lens (BCL) over the cornea. Sub conjunctival gentamycin and dexamethasone were delivered to minimise the risk of intra ocular infections and inflammation. The postoperative period was uneventful and the recovery was good. The visual acuity at 2 weeks postoperative period was 6/9 with fairly round pupil and no diplopia and glare.

Discussion

Iridodialysis causes polycoria which can be annoyingly symptomatic due to monocular diplopia and glare. Sometimes it can be cosmetically unacceptable. Iridodialysis can be classified into massive (More than 120 Degrees), moderate (45 to 120 Degrees), and minimal (less than 45 Degrees) depending on the extent of dialysis.8 Characteristically, the functional and cosmetic complaints are often encountered if iridodialysis occurs in the inferior, temporal or nasal aspects. Our patient had a large inferior iridodialysis which would have been symptomatic and caused cosmetic issues. Ever since BW Key described the first iridodialysis repair in 1932, various surgeons have been attempting the procedure with varied results.4, 6, 7, 9, 10, 8, 11, 12, 13, 14 Mc Cannel’s technique initiated a revolution in iris repair among ophthalmic surgeons.7 Sewing machine technique was originally described for iridodialysis subsequently got modified.7, 12, 13 Siepser slip knot,7 mattress suture14 and single pass four throw technique8 have been in vogue. Availability of number of techniques has provided the surgeons with options to choose from. Most of these procedures required straight suturing needles which may not be available in the operation theatre all the time and maneuvers are more complex. Often the anterior chamber could not be maintained stable during large iridodialysis repair. More importantly the iridodialysis repair procedure would have to be planned electively if it occurs during any other intra ocular procedures such as cataract surgery. Our technique was performed on the same sitting with the instruments generally used for conventional cataract surgery. Hence it can be done in camp setup with limited availability of instruments.

The advantages of this simple technique are:

  1. It can be performed with available instruments used for conventional cataract surgery.

  2. Anterior chamber stability is maintained.

  3. Minimal tissue handling.

Our novel and simple technique requires simple maneuvers and results in good functional and cosmetic outcome.

Limitation

The exteriorized suture on the cornea may cause irritation and pose a risk for infection. To address this, we had placed a BCL and the patient was closely monitored. Application of topical antibiotic drops were extended along with regular postoperative medications. Our patient’s post operative period was uneventful.

Conclusion

We have described this simple suture technique which would come in handy in urgent situations and need less expertise and minimal common surgical instruments.

Source of Funding

None.

Conflict of Interest

None.

References

1 

Y Okamoto S Yamada M Akimoto Suturing repair of subtotal iridodialysisInt Ophthalmol20183813958

2 

KVR Kumar Modified sewing machine technique for iridodialysis repair, intraocular lens relocation, iris coloboma repair, Cionni ring fixation, and scleral-fixated intraocular lensIndian J Ophthalmol2018668116976

3 

M Shekhar PR Menon Stay Back Technique" of scleral fixation of decentred intraocular lensbag complexIndian J Ophthalmol20227072777

4 

MO Yousif Single suture customized loop for large iridodialysis repairClin Ophthalmol201610188390

5 

RP Sangameswaran GK Verma N Raghavan J Joseph M Sivaprakasam Cataract surgery in mobile eye surgical unit: Safe and viable alternativeIndian J Ophthalmol201664118359

6 

Y Benayoun S Petitpas K Turki JP Adenis PY Robert Implants à fixation sclérale sans suture: série de neuf cas et revue de la littérature [Sutureless scleral intraocular lens fixation: report of nine cases and literature reviewJ Fr Ophtalmol201336865868

7 

RR Lian SB Siepser NA Afshari Iris reconstruction suturing techniquesCurr Opin Ophthalmol2020311439

8 

P Narang A Agarwal A Agarwal A Agarwal Twofold technique of nonappositional repair with single-pass four-throw pupilloplasty for iridodialysisJ Cataract Refract Surg20184412141320

9 

SS Pandav PC Gupta RR Singh K Das S Kaushik S Raj Cobbler's Technique for Iridodialysis RepairMiddle East Afr J Ophthalmol20162311424

10 

T Agarwal D Singh A Panda Guide needle-assisted iridodialysis repairJ Cataract Refract Surg201137101918

11 

M Stopa P Rakowicz Sutureless iris repair: cauterization techniqueRetina2015351226479

12 

KVR Kumar Sewing machine technique for iridodialysis repairDelhi J Ophthalmol201524424851

13 

KVR Kumar Modified sewing machine technique for iridodialysis repair, intraocular lens relocation, iris coloboma repair, Cionni ring fixation, and scleral-fixated intraocular lensIndian J Ophthalmol2018668116976

14 

RF Steinert Minimally invasive iris surgeryMinimally invasive ophthalmic surgerySpringerBerlin, Heidelberg20101539



jats-html.xsl


This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Article type

Case Report


Article page

616-619


Authors Details

Kiruthika Sekizhan, Premnath Gnaneswaran*, Shankar Chokkalingam, Rajakumari Murugesan


Article History

Received : 16-11-2023

Accepted : 14-02-2024


Article Metrics


View Article As

 


Downlaod Files