Surgery: Iridodialysis Repair

>> This patient was referred post-trauma. Has had a primary corneal laceration repair, and as one can see, a large five clock-hour iridodialysis, and the goal of the procedure here will be to repair the iridodialysis here, by suturing the iris root back to its insertion point. You can notice the laceration actually extended into the sclera. It can be visualized there. One notes here the peripheral iris is actually rolled and twisted around the pupil itself. And so the first goal here is to unravel and unroll that iris, to put it back into its normal physiologic position. This requires some dissection here, under the pupil here, avoiding to hit the lens. Using viscoelastic and previously some acetylcholine helps to perform this maneuver. This patient, remarkably, had a clear lens, and had reasonable visual acuity, and therefore we are doing this repair as a phakic iridodialysis repair, maintaining this patient’s lens status, particularly as this patient is young and has a clear lens, and although is at risk for developing cataract, certainly it can be dealt with later. The iris is now unrolled and unraveled, and one can see, now, the sheet of iris there, in the inferior aspect of the anterior chamber. Viscoelastic will continue to smoothen out the iris and flatten it. It’s important to get it completely unrolled. So we see the extent of the iris root. We now approximate the first margin here nasally, using a straight STC-6 needle, on 10-0 prolene, using a pair of micrograspers to facilitate passage of the needle through the peripheral iris, to proximate it with a 27-gauge hypodermic needle placed at the level of the scleral spur. This landmark is important to visualize. Here and here we’re using an ab externo technique here, to capture and dock the needle, as it’s pulled through the sclera itself. This is one approach here, using an ab externo approach, and the straight needle we find to be the easiest to pass across the anterior chamber in this manner. The second arm of the double armed 10-0 prolene is now used, and again, we’ll use in this case a microtier, to actually facilitate passage, hold the needle in the anterior chamber, while a micrograsper holds the iris, and here we’re gonna use an ab interno passage to pass the needle. Notice the bites are made along a longer arc length on the scleral side than on the iris side, to stretch the iris, where it will be reapproximated in the angle. Now we have our first pass mattress suture made. We will not tie it yet. We will then place the second mattress suture. Here we bend the distal aspect of that needle to facilitate the grasping of the needle with the needle driver. Again, we’re gonna place a pass here, just adjacent to the earlier pass of the second arm of that first mattress suture. Again, using an ab interno approach here to pierce the needle through the level of the sclera, at the level of the spur. Just posterior to the scleral spur. And then rotating the needle and passing it out in this manner, as you see here. The L-shaped needle, again, does help to facilitate the grasp of the needle with the needle driver externally. Again, approximately 2 clock hours apart, we will then pass a needle again through the very peripheral part of the iris here, ab interno, to place it through the sclera, just posterior to the spur. And the needle is then withdrawn from the eye. So now we have two horizontal mattress sutures placed through the peripheral iris. This is about a 5 clock hour dialysis, and in this case, we will use three vertical mattress sutures. You can see we’re just adjusting the sutures here without tying them, to allow some laxity of the iris, to facilitate visualization of the remaining passes. Again, notice the penetration of the sclera is made along a wider arc, compared to the initial passes through the iris. This allows the iris to, in some ways, fan out again, to help spread it across the angle at its insertion point, and therefore it’s important to ensure that we try to maintain that relationship. We then place our third mattress suture here. We’re using a Sinskey hook just to make that needle tract a bit larger, to help facilitate the rotation of the knot after we tie it. And then we will tie each mattress suture in a slipknot fashion to allow the ability to tighten and loosen. It’s important to be able to do this, as sometimes we do allow the iris to hang back just slightly, to avoid excessive pupillary distortion and ovalization. As long as we get that iris near that root, that’s what’s important here in this case. Typically, the iris is sheared off at the insertion. But sometimes there is actually some remaining iris in that angle there that one has to take into consideration. The slipknots are then tied again, as we see here. Continuing to do these three sutures here. And you can see we’re actually loosening them a little bit, as we thought perhaps one of them were a little tight there, and this allows us, again, to titrate the tension, using a slipknot. Again, we see here that that first mattress suture that was tied is tightened a bit more. We have not locked the sutures yet. We will do that after we finalize the throws on each of these suture passes here. And again, two throws in the same direction allows us to do this. Once we have this performed, we can then lock the knots, as we’ll see shortly, and this allows us, again, to ensure we have adequate iris and pupillary architecture. We then smoothen out the iris. A bit of Miochol and a bit of viscoelastic, again, just to eliminate any potential folds or entrapment of the iris into the angle. And now we will lock the knots here, again, using a reverse throw to lock the knots, cut them, trim the knots, and we will then rotate the knots into the sclera. Notice we have not used any grooves or flaps here. We find it not necessary. As long as we have that not rotated and buried in the sclera, the sutures are quite stable, and the risk of erosion is quite low. A pair of curved tiers helps us to place it through that hole. Remember, this first pass was made with a 27-gauge needle, so that’s easy to rotate. The second and third mattresses were done ab interno, and that Sinskey hook helps us to get through. Again, we’re gonna use a pair of micrograspers here, to help pull the iris, to ensure no iris has been entrapped in the knot or in that mattress suture. This really helps to make sure we round out that pupil as much as possible. Sometimes it’s necessary to suture and do a partial pupillary cerclage or pupilloplasty suture, if that pupil is distorted or if there’s sphincter damage. In this case, we didn’t have this, and therefore the pupil remained as is, without suturing. Finalizing the case by removing the viscoelastic manually. This is again done with a patient who has a phakic status here. And we’ll use some fibrin glue to close the conjunctiva over the sclera. We managed to do this case without traumatizing the lens, although there is, of course, a long-term risk for cataract formation just from the trauma. And from the surgery as well. But we managed to do this without damaging the crystalline lens. We’ll use a little bit of ReSure, some polyethylene glycol here, to just seal the wounds, to ensure we have water tight closure here, after the manipulation through the incisions here. Just one more way to close the incisions without sutures. This just acts a little different than the fibrin glue, of course. Acts more as a sealant, as opposed to an adhesive type of application here. In summary, this is an iridodialysis repair in a phakic patient.