Pigment vacuum iridectomy for phakic

refractive lens implantation

Kenneth J. Hoffer, MD
ABSTRACT
I present a technique designed to ensure an atraumatic patent basal iridectomy for phakic
refractive lens implantation. The technique divides the iridectomy procedure into 2 steps.
First, the stromal layer is removed by surgical excision. Then, the pigment layer is removed
by gentle vacuum aspiration with a 25 gauge cannula. Atraumatic, small, basal peripheral
iridectomies that are functional and cosmetically pleasing have been performed in 12 eyes.
There were no cases of large amounts of pigment debris deposited in the trabecular
meshwork as checked by gonioscopy. Pigment vacuum iridectomy may be a reliable
procedure to ensure a proper basal iridectomy in any type of anterior segment eye surgery.
J Cataract Refract Surg 2001; 27:11661168 2001 ASCRS and ESCRS
T
he peripheral iridectomy, the bane of many eye
surgeons, seemed to become unnecessary in the age
of modern posterior chamber intraocular lens (IOL) im-
plantation. Gills first recommended its elimination in
uneventful cases more than 10 years ago. Because of this,
many surgeons have become rusty in the finesse and
technique of performing a perfect surgical iridectomy.
Peripheral iridectomies are still necessary in some
cases and mandatory in cases of anterior chamber IOL
implantation. An iridectomy is also mandatory in pha-
kic IOL implantation in refractive surgery, whether the
lens is an anterior chamber, iris-supported, or posterior
chamber model. Surgeons have the option of perform-
ing 1 or 2 peripheral iridotomies using a neodymium:
YAG(Nd:YAG) or argon laser or to create an iridectomy
surgically at the time of phakic IOL implantation.
The advantage of an Nd:YAG iridectomy is that it
can be performed in an office setting, allowing the sur-
geon to ensure its patency before implanting an IOL.
The disadvantages are as follows:
1. It requires 2 procedures (iridotomy and phakic IOL
implantation).
2. On rare occasions, it can be painful if retrobulbar
anesthesia is not used.
3. It becomes unnecessary if IOL implantation is never
performed.
4. It can be difficult to ensure its patency.
5. It can be too small and, on rare occasions, may reseal.
6. Dense pigment particles are deposited in the angle
meshwork (potential blockage).
7. It is more difficult to make a truly basal opening.
The advantages of a surgical iridectomy are the op-
posite of those of the Nd:YAG iridectomy, while the
disadvantages are as follows:
1. Intraocular bleeding, including 8-ball hemorrhage,
can occur.
2. There is a risk of injury to the crystalline lens, causing
cataract.
3. If the iridectomy is too large, it may cause optical
second-image glare.
4. It is technically difficult to make a small, truly basal
peripheral iridectomy.
5. It is technically difficult to cut both the stromal and
pigment layers in 1 maneuver.
Accepted for publication February 19, 2001.
Reprint requests to Kenneth J. Hoffer, MD, St. Marys Eye Center,
1441 Broadway, Santa Monica, California 90404, USA. E-mail:
[email protected].
2001 ASCRS and ESCRS 0886-3350/01/$see front matter
Published by Elsevier Science Inc. PII S0886-3350(01)00845-8
Figure 1. (Hoffer) A Zaldivar iridectomy forceps and scissors are
used to excise basal iris stroma through a 1.5 mm limbal incision.
Figure 2. (Hoffer) Viscoelastic material is injected over the iridec-
tomy site covering the pigment layer.
Figure 3. (Hoffer) A: The pigment layer is aspirated with a 25 gauge cannula on a BSS syringe. B: The pigment layer is further aspirated. Note
red reex. C: The remaining pigment layer is aspirated.
Figure 4. (Hoffer) The pigment particulate matter is irrigated onto
the conjunctiva.
Figure 5. (Hoffer) The nal status of the phakic eye after phackic
IOL implantation and surgical pigment vacuum iridectomy.
TECHNIQUES: HOFFER
J CATARACT REFRACT SURGVOL 27, AUGUST 2001 1167
6. The lens may be damaged when the surgeon at-
tempts to open the remaining pigment layer.
I developed a simple method of performing a surgi-
cal iridectomy that eliminates many of its disadvantages.
Surgical Technique
To best obtain access to the basal iris, rather than
making a shelved incision, the surgeon should make the
incision in the corneal limbus in an approach that is
perpendicular to the iris plane. To be sure there is
enough room for the instruments to function, the
incision should be at least 1.0 mm wide, but no larger
than 1.5 mm so that the perpendicular cut will be
self-sealing.
Because 2 layers of the iris (stroma and pigment
layer) are easily separated, deep forceful purchase of the
iris with the forceps is required to pull both layers
through the incision in 1 maneuver, similar to grabbing
the bedspread and the sheet without pressing on the
mattress. With this technique, the initial step ignores the
pigment layer, allowing the surgeon to concentrate on
grasping only the iris stroma for traction through the
incision and excision. Thus, excess force on the crystal-
line lens or zonular fibers is not necessary. Because the
pigment layer is ignored, the surgeon is better able to
focus on pulling out and excising only a small piece of
iris stroma. I use a Zaldivar iridectomy forceps for the
stromal excision, but any fine iridectomy forceps would
work as well. Any small scissors can be used for the
excision (Figure 1).
After the iris stroma has been cut, a layer of sodium
hyaluronate 1%(BioLon) is placed over the iridectomy
site (Figure 2) and the area is inspected under high mi-
croscopic magnification. A 25 gauge cannula attached
to a small syringe half-filled with balanced salt solution
(BSS) is then placed through the incision and maneu-
vered just over the remaining pigment layer. Gentle
aspiration allows complete, careful vacuuming of the
entire exposed pigment layer, completing the procedure
(Figure 3). The consistency of the pigment layer is
much different from that of the stromal layer. It has
the appearance of clumps of dust packed together.
The layer is very friable and easily broken up by
aspiration.
It is important not to use the same syringe to later
hydrate the corneal incisions becauses pieces of pigment
(Figure 4) will be forcibly imbedded into the corneal
stroma, causing a tattoo that is only cosmetic.
Iridectomy patency is confirmed by observing the
red reflex under high microscopic power.
Results
This procedure was been performed in 12 eyes with-
out untoward sequellae (Figure 5). All eyes had small
basal iridectomies that were not too large or too close to
the pupil. Gonioscopy was performed preoperatively in
all eyes. Postoperative gonioscopy showed minimal to
no iris pigment deposition in the trabecular meshwork.
Patients were thoroughly questioned and did not report
glare resulting from the iridectomy. After the learning
curve, surgeons can perform this technique with their
overall procedure without appreciably extending the du-
ration of the operation.
Discussion
The technique of pigment vacuum iridectomy al-
lows the surgeon to be more assured that the iridectomy
is totally patent and functional. It relieves the stress of
attempting to excise both layers of the iris at one time,
decreasing potential trauma to the crystalline lens and
zonular fibers in phakic eyes as well as to zonular fibers in
aphakic eyes. It facilitates the creation of a truly basal
iridectomy while decreasing the chance of making the
opening so large that it may lead to glare symptoms,
especially in patients with poor lid coverage of the supe-
rior iris. It may decrease the deposition of dark pigment
particles in the trabecular meshwork, which may cause
future obstruction of the drainage system and increase
the risk of glaucoma damage. In the 12 eyes in which this
technique has been used thus far, the iridectomies have a
good cosmetic appearance.
This technique may help lessen a disadvantage of
phakic refractive IOL implantation surgery; that is, the
necessity of a patent peripheral iridectomy.
TECHNIQUES: HOFFER
J CATARACT REFRACT SURGVOL 27, AUGUST 2001 1168