CORNEA

Six Essentials to Iris Repair

In the first of a multi-part series, Dr Soosan Jacob describes an introduction to the basics of iris repair.

DR SOOSAN JACOB REPORTS

I
ris repair is an integral part of many ocular surgeries, and through the iris stroma. The formed radial network can bleed
every anterior segment eye surgeon should learn a few basic into the anterior chamber (AC) during surgical iris trauma.
techniques. Usually performed as part of anterior segment re-
construction, it is sometimes also required of cataract surgeons, Synechiolysis
e.g., in case of iris damage following continual iris prolapse in Peripheral anterior synechiolysis is sometimes needed in pa-
intraoperative floppy iris syndrome. Complex surgeries that tients with prior surgery or other pathology. The iris should be
require peripheral anterior synechiolysis or release of posterior carefully examined for signs of neovascularisation, atrophy, or
synechiae may also necessitate iridoplasty techniques. prior defects. In every synechiolysis case, care should be taken
In addition, sometimes one may need to operate on a patient to keep the AC pressurized, which may be done using viscoelas-
with cataract co-existent with pre-existing iris damage—either tic or an AC maintainer and working through small incisions.
as part of a pathology (e.g., iridocorneal endothelial syndrome) Pressurization of the chamber is important to rapidly tamponade
or secondary to post-traumatic/iatrogenic iris damage. In all any possible bleeding from the iris. Hypotony will delay clotting
these situations, it is beneficial to be well-versed in basic iris and keep blood oozing for longer. Synechiolysis should be done
repair techniques. This multi-part series on iris repair will cover gently by viscodissection, and if this proves difficult, then with
everything about the topic. either the rounded viscoelastic cannula or a blunt rod. Rough
manoeuvres should be avoided as this can lead to iris tears,
Iris anatomy iridodialysis, and even Descemet’s detachment.
The iris consists of the pupillary and ciliary zones, with the Posterior synechiolysis is required in some cases, espe-
thickest part the collarette (lying 2 mm around the pupil) and cially post-uveitic cataracts. These can also often be re-
the thinnest the iris root. The circular sphincter pupillae and the leased by gentle viscodissection. However, the pupil may
radial dilator pupillae constrict and dilate the pupil, respectively. remain non-dilating, and if additional procedures (such
The pupillary ruff is the dark border of the pupil and formed by as cataract extraction, IOL explantation, or vitrectomy) are
the posterior pigment epithelium wrapping around the pupillary needed, some other pupillary dilatation technique such as
margin. The anterior ciliary and long posterior ciliary arteries mini-sphincterotomies, iris hooks, B-Hex, or Malyugin ring
anastomose in the ciliary body (CB) to form the major and minor may be needed. Some of these cause iris tears and need iris
arterial circles that lie in the anterior part of the CB and along repair, while others are gentler on the sphincter and do not
the pupillary border and are joined by radial vessels weaving need additional procedures.

Iridectomy
Though iridectomy is not a type of
iris repair, it is sometimes required in
combination with anterior segment
reconstruction surgeries and often
required during glaucoma, corne-
al, or vitreoretinal procedures. A
peripheral iridectomy is best done
in the superior periphery but may
be required inferiorly to prevent a
pupillary block when air or silicone
oil is left in the eye. It may be done
preoperatively using a YAG laser
but also intraoperatively using a vit-
rector in I/A-cut mode with a very

LEGEND FOR FIGURE:

Figure: A) Post-uveitic peripheral ante-
rior synechiae. B, C) Iris membrane dis-
section with a sharp 23-gauge needle.
This fibrous membrane can be removed,
freeing up the iris below for reconstruc-
tion. D) Iridectomy with a vitrector.

26 EUROTIMES | FEBRUARY 2024

low cut rate and vacuum of about 300 mmHg. It is done after Management of iris defects without intraocular surgery
constricting the pupil using intracameral miotics. Iris defects may exist from a previous surgery or trauma.
In pseudophakic eyes, Fang et al. have described a tech- This may result in photophobia, difficulty looking at light,
nique of introducing a sharp needle (with its tip bent to 45 polyopia, stray light, etc. Iris defects may be managed con-
degrees) posterior to the iris that is bellowed upwards with servatively using tinted glasses or aniridic contact lenses,
viscoelastic.1 The bend is held horizontally to prevent iris which have a clear central optic zone and a coloured pe-
snag and, once in position, turned anteriorly to engage the iris riphery. Focal corneal tattoos may also be helpful in certain
while applying posterior pressure with an iris repositor. The situations—e.g., if a peripheral iridectomy or an iridodialysis
puncture is then enlarged with a microscissor. The approach is not covered by the lid, causing symptoms. It can also be
should be from a comfortable angle for both instruments. used for traumatic iris defects and aniridia. Tattoo applica-
Techniques that involve cutting the iris directly below the tion can be superficial or intra-lamellar into a femtosecond
base of an incision run the risk of a poorly positioned iridecto- laser-created channel.
my and iris base damage. The next article in this series on iris repair will deal with
pupilloplasty techniques. Stay tuned!
Iris membranes
The iris is a pro-inflammatory structure and iris membranes For citation notes, see page 48.
can often form, especially after severe episodes of intraocular
inflammation. These membranes are fibrotic with varying
levels of vascularisation and can hold the iris fixed in differ-
ent positions. Membrane peeling can be done from over the
iris using a combination of instruments. The sharp point of a Soosan Jacob MS, FRCS, DNB is Director and Chief of Dr Agarwal’s Refractive
23-gauge needle can be inserted under the membrane, and the and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be
membrane gently dissected off the iris. Microforceps and mi- reached at [email protected].
croscissors can also be used to cut fibrous strands and remove
them. Often, the entire iris then becomes mobile and free if not
excised during any previous surgery. This freed iris tissue can
then be pulled into position for iridoplasty.

Pupillary fibrous membrane

Sometimes a pupillary membrane may be found occluding the
pupil, especially if associated with pre-existing uveitis, rubeo-
sis, trauma, or post-surgical inflammation. This may be peeled
off using microforceps or, if difficult, cut and removed using a
combination of microforceps and microscissors or even a vitrec-
tor. In case of phakic eyes, care should be taken not to damage
the lens. Sometimes, a fibrous band may encircle the pupillary
aperture, and this can also be removed using microforceps.

iLEARN
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free for ESCRS members.
Visit elearning.escrs.org to access over 30
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e-learning content, including surgical videos,
diagrams, animations, quizzes, and forums.

2024 FEBRUARY | EUROTIMES 27

 CORNEA

Knowing Iris Repair: Pupilloplasty

This second of the series on iris repair covers everything pupilloplasty.

DR SOOSAN JACOB MS, FRCS, DNB

T
he iris plays an important visual function, modulating Kuglen hook passed through a paracentesis created between
entry of light as well as controlling the effect of high- the two limbal sites and a single or double knot is slowly and
er-order aberrations. In addition, an abnormally posi- gently tightened to approximate the iris edges. Further knots
tioned iris can result in complications such as glaucoma or an are then thrown. The McCannel suture has the disadvantage
increased risk of corneal graft rejection. The iris also plays an of traction on the iris towards the paracentesis while tighten-
aesthetic role, especially in light-coloured irides. ing the knots that may not be tight enough.
Pupilloplasty can be done for visual purposes to decrease
glare or reduce the effect of HOAs, for anatomical reasons to Siepser sliding knot
create a taut iris diaphragm and prevent peripheral anterior Siepser modified the McCannel suture in 1994 by introduc-
synechiae, or for aesthetic reasons, e.g., to correct an ectopic ing the sliding knot to make tightening easier and less trau-
pupil or close an iris defect in light-coloured irides. matic to the iris. It gives a tighter knot and better approxi-
Iris reconstruction should therefore be an essential skill for mation of the iris. Here, the knot is tied outside the eye and
all anterior segment surgeons. In the second of this multi-part then drawn in to be tightened over the iris.
series on iris repair, we will discuss various pupilloplasty A long, thin, curved needle on a 10-0 Prolene suture is
techniques, some which can also be used for haptic fixation to passed from the limbus through the first and second limbs of
the iris. the iris and then railroaded into a 26-gauge needle passed into
Most iris reconstruction techniques use a 10-0 or 9-0 Pro- the anterior chamber (AC) through a limbal paracentesis and
lene suture on a long, thin, and curved CI-4 needle, though thus brought out. A Sinskey or Kuglen hook is passed through
a long and straight needle may also be used if curved is the paracentesis and the initial length of the suture before the
unavailable. Pupilloplasty is difficult in phakic eyes for fear of first pass through the iris is hooked and brought out through
damage to the crystalline lens from the needle passes and are the paracentesis in the form of a loop. The trailing segment is
also not preferred because of the difficulty during a subse- then passed over and under one side of the retrieved loop to
quent cataract extraction. Thus, if pupilloplasty is required, it create the knot.
is preferable to do a cataract surgery and implant the IOL first.
Osher’s modification
McCannel suture Professor Robert Osher’s modification of the Siepser knot
Introduced in 1976, the McCannel suture technique uses a created two consecutive slip knots around a carefully
10-0 Prolene suture on a long needle introduced through the untwisted, retrieved suture loop—the first one tightened
limbus and passed through the approximated first and second after passing the cut end twice around the strand emanat-
iris edges and out the limbus on the other side. The suture ing from the iris, followed by retrieval of the loop again to
on either side of the iris is then retrieved with a Sinskey or create one locking knot.

30 EUROTIMES | MARCH 2024

Figure:
A–C) The 10-0 Prolene and the 30-gauge needle are, respectively, passed through the limbs of the iris on either side. The long needle on
the 10-0 Prolene suture is railroaded into the 30-gauge needle and externalized through the paracentesis. D) A loop of the suture is pulled
out through the paracentesis. E) The cut end of the suture is thrown four times around the loop. F) Pulling apart the two suture ends on
either side results in the knot sliding in and tightening the two limbs of the iris snugly.

Condon’s modification Pinhole pupilloplasty (PPP)

Dr Garry Condon modified the Siepser knot by using forceps to As described by Dr Agarwal, the pupil is made pinhole sized
wrap one side of the loop around the suture, just as in a simple to remove the effect of HOAs and improve visual acuity in
double throw knot. eyes with high amounts of irregular astigmatism.

Single-pass, four-throw pupilloplasty Open-sky pupilloplasty

Dr Amar Agarwal modified this further by using only a single A pupilloplasty is often needed in combination with a pen-
pass and four throws. A paracentesis is created at the site etrating keratoplasty. In this case, an open-sky pupilloplas-
through which the needle will emerge after the second iris ty may easily be done. A short, curved needle on a 10-0
pass. Any pre-existing paracentesis sufficiently close may also nylon suture is often easier to pass than the long, curved
be used instead. needle attached to the 10-0 Prolene suture. Care should be
The first limb of the iris to appose is held with a micro- taken to avoid excess pulling to avoid any tug on the ciliary
forceps that passes through this paracentesis. A 10-0 Prolene body in the open-sky state.
suture on a long, thin, curved CIF-4 needle or a straight STC-6
needle is passed trans-limbally through the iris root, suffi- Complications
ciently close to the edge to prevent undue iris bunching but There must be enough stretch in the iris to bring the limbs
with sufficient gap to prevent cheese-wiring. The needle is together from either side. If pulled without sufficient laxity
then carefully released and allowed to rest freely. Followed for the two limbs to appose, the suture can cheese-wire
by a 30-gauge needle passed through the paracentesis, taking through the iris, or the iris can detach from its root, creating
care not to engage corneal tissue. an iridodialysis and bleeding into the AC. Excessive stretch
The second limb of the iris is held firmly by a microfor- can also result in iris stromal tears, iris hole creation, etc.
ceps passed through a second paracentesis, and the 30-gauge Extensive manipulation can result in postoperative iritis.
needle is passed through the iris, again close to its edge. The
needle on the 10-0 Prolene suture is docked into this 30-gauge
needle and railroaded out through the paracentesis. A Kuglen
or Sinskey hook draws a loop of the initial pass of the suture
out through the paracentesis. The free end of the suture is
then cut and looped four times around the externalized loop.
The two ends of the suture on either side of the limbus are
then pulled in opposite directions—this internalizes the knot
and tightens it over the iris, bringing the two limbs of the iris Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea
together. Advantages include ease of surgery and the ability Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at
to use either limb of the externalized loop. [email protected].

2024 MARCH | EUROTIMES 31

 CORNEA

In the Know—Iris Repair, Part 3

The third of this multi-part series reveals key techniques no surgeon should pass.

DR SOOSAN JACOB MS, FRCS, DNB

I
ridodialysis refers to a separation of the iris from the ciliary are pulled, drawing the loop into the AC and against the
body at the iris root. It can be post-traumatic or iatrogenic. iris. The externalized sutures are then cut and tied down to
Small iridodialysis, especially if covered by the upper lid, appose the iris against the scleral wall. Overtightening the
may be ignored, but larger dialysis can cause visual symp- prolene suture can occur easily, so the knots should be tight-
toms such as glare, photophobia, and monocular polyopia. It ened carefully. Multiple such passes of double-armed pro-
also causes polycoria and often results in a displaced pupil. In lene suture are required for a large dialysis area. The knots
light-coloured irides, it causes cosmetic concerns as well. are pushed deep into the scleral groove, and the conjunctiva
is closed. A partial thickness scleral flap is sometimes used
Contemporary iridodialysis techniques instead of a scleral groove to avoid exposed knots.
When suturing the iris back, the first step is to make a perito-
my and create a scleral groove about 1.5 mm behind the Hoffman pocket
limbus. Next, the anterior chamber (AC) is filled with visco- The scleral groove technique can result in exposed knots—
elastic, and the iris straightened out with all folds removed leading to the introduction of the Hoffman pocket to avoid
and brought to lie in the final intended position, using a this problem. A tunnel is created backwards from the limbus
double-armed 10-0 prolene suture with two long, thin, and into the sclera, and the two needles of the double-armed
preferably curved needles (CIF-4, Ethicon) on either side. A suture exit through the roof of this pocket. These are then cut
paracentesis is made on the side opposite to iridodialysis, and withdrawn from within the pocket by pulling them out
and one of the needles is passed carefully through the para- with a rod or Sinskey hook. Tying the two ends of the suture
centesis into the iris near the dialyzed root and docked into buries the knot within the tunnel. This technique has the add-
a 30-gauge needle passed through the scleral groove, then ed advantage of not requiring any conjunctival peritomy.
railroaded out through the sclera. The second needle is then
passed through the iris stroma about one clock hour away Scleral tunnel
from the previous pass and again railroaded into a needle A technique similar to the Hoffman pocket, this follows a
passed through the scleral groove radial to it and a short conjunctival peritomy with the creation of a scleral tunnel
distance away from the first one. starting about 2.0 mm posterior to the limbus. The needles
Care should be taken to ensure a free loop between the are externalized from the roof, and the cut suture ends are
two needles. Once both needles have been externalized, they pulled out through the scleral pocket and tied within it.
This method has the disadvantage of
needing a conjunctival peritomy. If a
scleral tunnel is already created for
some other purpose—e.g., rigid IOL
explantation or manual small inci-
sion cataract surgery—an underlying
iridodialysis can be sutured to the
scleral tunnel floor.

Hang-back technique
An overtightened knot can result in
an updrawn pupil. In the hang-back
technique, the double-armed sutures
are tied down with enough slack

Figure 1, Trocar-assisted iridodialysis

repair: A) Irdodialysis during Descem-
et’s membrane stripping in endothelial
keratoplasty; B–C) Double-armed 10-0
prolene sutures passed through a trocar
inserted into the paracentesis and out
through the iris root and the floor of
a scleral groove; D) Tying down the
sutures results in iridodialysis repair.
Resultant knot is pushed into the pocket.

32 EUROTIMES | APRIL 2024

to give a cosmetically and visually ideal outcome. The
non-appositional closure results in an iris literally hung
back from the sclera.

Trocar-assisted iridodialysis repair

Take care passing the needles into the AC to avoid
snagging onto corneal fibres at the paracentesis—which
results in the prolene suture catching at the incision and
not being able to be pulled freely into the AC. Such a
situation necessitates cutting the suture and restarting. A
simple modification, described by Dr Amar Agarwal, uses
a trocar passed through the paracentesis. Passing the dou-
ble-armed needles through the trocar removes any chance
of the needle accidentally engaging corneal tissue during
its passage. The trocar can be removed once the loop lies
free within the AC.

Cobbler’s technique
This technique allows easy and rapid repair of the entire
iridodialysis through a small incision and without repeated
entry and exit or AC shallowing. One end of a 10-0 prolene

Research
suture is threaded through a 26- or 27-gauge needle, which
then passes from a diametrically opposite paracentesis into
the AC to take a bite of the iris periphery and exit through
a slanting scleral groove. The cut end of the suture is
retrieved outside the eye while the needle is again internal-

Education
ized, only to be passed through an adjacent part of the iris
and scleral groove. This time, a loop of suture is retrieved,
and the needle reinternalized. This repeats as many times
as required to cover the entire dialyzed iris, creating mul-
tiple loops. The initial free end is then passed through all

Innovation
loops except the last one and tied down to the cut end of
the last loop. Cobbler’s technique requires only one knot
instead of multiple knots.

Rivet technique
The cut end of a 6-0 prolene suture is flanged using
a low-temp cautery. A 26-gauge needle then passes
through the sclera and the dialyzed iris periphery. The
free end of the suture passes into the needle, and the
needle withdrawn. The flanged end apposes against the ESCRS’s vision is to educate and
iris and pulls it towards the scleral wall. The other end help our peers excel in our field.
is trimmed sufficiently and also flanged to ensure iris
apposition and the flange burial in the sclera. Together, we are driving the field
of ophthalmology forward.
Flanged repair
Two ends of a 6-0 prolene suture are passed through the
peripheral iris and out through the sclera. Both ends are
drawn so the internal loop brings the iris against the
sclera, then flanged with a low-temperature cautery and
buried in the sclera.

Soosan Jacob MS, FRCS, DNB is Director and Chief of Dr Agarwal’s

Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai,
India, and can be reached at [email protected].

2024 APRIL | EUROTIMES 33