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Preplaced inferior iris suture method for small pupil phacoemulsification
Preplaced inferior iris suture method for small pupil phacoemulsification Samuel Masket, M.D.
Maintaining pupil form and function is essential to the success of cataract rehabilitation, particularly if disabling glare is the indication for surgery. Patients with poorly dilating pupils preoperatively present a significant challenge to the surgeon to maintain the normal pupil. A number of surgical approaches for the small pupil beyond synechiolysis have been recommended (Table 1), yet most procedures that fully transect the pupillary sphincter are likely to leave the pupil aesthetically deformed or functionally deficient (Figure 1). One recently described method l for preserving the round pupil is a series of incomplete sphincterotomies designed to increase work space without disfiguring the pupil. (Personal experience with this technique indicates that it is most useful for moderately small pupils and that posterior synechias that bind the pupil are common after surgery.)
Some surgeons advocate manual nucleus expression (through an obligatory large incision) instead of phacoemulsification in cases with miotic pupils. However, nucleus expression in cases with small and rigid pupils, notably in glaucomatous eyes subjected to miotic therapy, risks permanent sphincter damage and an atonic, deformed pupil postoperatively. Moreover, it is advantageous to use small incision methods when performing cataract removal in eyes with concurrent glaucoma to preserve sufficient space should filtration surgery become necessary. Techniques that allow operative enlargement of the pupil for phacoemulsification yet preserve the function and appearance of the pupil are particularly valuable. As surgical experience is gained one may perform endolenticular emulsification without pupillary enlargement. However, for transitional surgeons or in cases with pupils less than 3.5 mm in diameter, it is generally
Presented in part at the Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, March 1990. Figures 2-5, 7, 9-12, 14-17, and Table 1 reprinted from Nordan LT, Maxwell WA , Davison JA, eds, The Surgical Rehabilitation of Vision, New York, Gower Medical Publishing, 1992, with permission of the publisher. Reprint requests to Samuel Masket, M.D., Suite 204, 7230 Medical Center Drive, West Hills, California 91307-1957. 518
J CATARACf REFRACf SURG-VOL 18, SEPTEMBER
1992
Table 1. Traditional methods for pupil enlargement. Synechiolysis Sector iridectomy Inferior/radial sphincterotomies Multiple incomplete sphincterotomies Postplaced suture of iris defects
preferable to enlarge the pupil. One method incorporates the combination of a superior radial full sphincterotomy with preplacement of a superior iris suture, as described by Neuhann and Grabow (Thomas Neuhann, "The Technique of Iridotomy and Iris Suture in Cases of Excessive Miosis"; Harry Grabow, "McCannel Suture Technigue for Phacoemulsification with Foldable IOL Through Miotic Pupil and 4-mm Incision." Welsh Cataract Congress, Houston, November 1988). Preplacement of the permanent iris suture assures proper alignment of the iris pillars and results in a physiologic pupil, as seen in Figures 2 and 3. I have modified the preplaced iris suture method by moving the sphincterotomy inferiorly, to the 6 o'clock position, to enlarge the work space in the inferior aspect of the chamber where most endolenticular or fracture forms of phacoemulsification are generally performed. The superiorly oriented method seems most appropriate for bimanual iris plane phacoemulsification which requires visibility and working space in the superior aspect of the chamber. For current in-the-bag techniques of endolenticular phacoemulsification,
Fig. 1.
(Masket) Postoperative appearance of pupil after five small radial sphincterotomies. Aesthetic appearance is unsatisfactory, particularly in cases with light-colored irides.
Fig. 2.
(Masket) Postoperative appearance of pupil after preplaced suture with superior radial iridotomy. A small notch at the margin of the pupil is evident but not aesthetically significant.
Fig. 3.
(Masket) Eye in Figure 2 after pharmacologic dilation. The pupil appears normal and functions normally.
Fig. 4.
(Masket) The pupil is miotic and has synechias to the anterior lens capsule. Synechiolysis is performed; in certain cases, it may enlarge the pupil sufficiently for cataract surgery.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
519
Fig. 5.
(Masket) After the anterior and posterior chambers are filled with copious amounts of viscoelastic material, a 10-0 polypropylene suture is guided through the inferonasallimbus by an ultrasharp, thin, straight needle (Ethicon STC-6).
Fig. 7.
(Masket) The needle is brought across the chamber to exit at the inferotemporallimbus. Occasionally it is helpful to guide the needle with a blunt instrument passed through a side-port limbal incision. Alternatively, the sharp needle may be retrieved in a fine cannula or needle passed through an inferotemporal limbal puncture.
Fig. 8.
(Masket) The inferior iris is fully transfixed by a single strand of 10-0 polypropylene.
Fig. 9.
(Masket) A microhook is passed through the superior incision and used to loop the suture from the underside of the iris.
however, greater visibility in the inferior aspect of the chamber is required.
TECHNIQUE The inferior sphincterotomy with preplaced suture method is detailed in Figures 4 through 15. As seen in Figure 4, posterior synechias are often noted in cases with miotic pupils; synechiolysis may expand the pupil adequately for surgery. In this case, however, I enlarged the pupil. Suture placement using an ultrasharp, straight, thin (sixwire) needle (Ethicon STC-6) is demonstrated in Figures 5 through 7. To protect the cornea and anterior lens capsule the anterior and posterior
Fig. 6.
520
(Masket) The sharpness of the needle allows easy transfixation of the inferior iris sphincter. The needle has to pass through the full thickness of the iris tissue but not damage the underlying lens capsule.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
chambers are hyperexpanded with a viscoelastic agent prior to suture passage. The completed suture (Figure 8) must be looped to allow for a generous inferior sphincterotomy (Figures 9, 10). The free ends of the suture are then retrieved th.rough an inferior limbal puncture in the manner of a McCannel suture 2 (Figures 11, 12). After continuous circular capsulotomy is completed, nucleus fracture endolenticular phacoemulsification (Figure 13) and cortex removal prepare the eye for lens implantation (Figure 14). The preplaced suture is tied securely at the inferior limbal puncture, the knot cut short, and the iris reposited, completing the surgical method (Figure 15). Fig. 12.
(Masket) The microhook is passed through the inferior limbal opening and used to retrieve one of the free ends of the polypropylene suture. The remaining end is grasped with a tying forceps for stability. After both ends of the suture are brought through the inferior limbal puncture, the free ends are taped to the drapes with a steristrip to prevent accidental traction and dislodgment of the suture.
DISCUSSION The technique described provides one method for maintaining the pupil in cases with preoperative miosis. Postoperatively the pupil functions well, appears normal, and dilates in response to
Fig. 10.
(Masket) While carefully avoiding the looped suture, the inferior iris sphincter is cut with Vannas scissors.
Fig. 13.
(Masket) Phaco and fracture endolenticular phacoemulsification is performed after continuous circular tear anterior capsulotomy.
Fig. 11.
(Masket) A self-sealing inferior limbal incision is created with a supersharp blade.
Fig. 14.
(Masket) After lens emulsification and cortical aspiration, the eye is ready for IOL implantation.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
521
Fig. 15.
(Masket) Following IOL implantation the polypropylene iris suture is tied with moderate traction at the inferior limbal puncture, completing the preplaced suture closure of the inferior iris sphincter, resulting in "normal" pupillary shape.
Fig. 16.
(Masket) Undilated appearance of pupil after the inferior preplaced suture method.
Fig. 17.
(Masket) Dilated view of eye in Figure 16 after pharmacologic dilation. As with the superiorly placed suture method (Figures 2, 3), the pupil appears normal and functions normally.
pharmacologic agents, as seen in Figures 16 and 17. The method may be used for very small pupils; in rare instances both the inferior and superior sphincter may be enlarged with preplaced sutures and sphincterotomies. One possible drawback, however, is the increase in surgical time necessary for placing and positioning the iris suture. Nevertheless, my data suggest an iris suture is essential in maintaining a normal pupil postoperatively and providing adequate work space intraoperatively.3 Methods for managing the poorly dilating pupil must consider these criteria.
REFERENCES 1. Fine IH. Pupilloplasty technique to improve cosme sis and preserve function after cataract surgery. In: Nordan LT, Maxwell WA, Davison JA, eds, The Surgical Rehabilitation of Vision. New York, Gower Medical Publishing, 1992
522
2. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7(2}:98-103 3. Masket S. Relationship between postoperative pupil size and disability glare. J Cataract Refract Surg 1992; 18:506-507
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
Maintaining pupil form and function is essential to the success of cataract rehabilitation, particularly if disabling glare is the indication for surgery. Patients with poorly dilating pupils preoperatively present a significant challenge to the surgeon to maintain the normal pupil. A number of surgical approaches for the small pupil beyond synechiolysis have been recommended (Table 1), yet most procedures that fully transect the pupillary sphincter are likely to leave the pupil aesthetically deformed or functionally deficient (Figure 1). One recently described method l for preserving the round pupil is a series of incomplete sphincterotomies designed to increase work space without disfiguring the pupil. (Personal experience with this technique indicates that it is most useful for moderately small pupils and that posterior synechias that bind the pupil are common after surgery.)
Some surgeons advocate manual nucleus expression (through an obligatory large incision) instead of phacoemulsification in cases with miotic pupils. However, nucleus expression in cases with small and rigid pupils, notably in glaucomatous eyes subjected to miotic therapy, risks permanent sphincter damage and an atonic, deformed pupil postoperatively. Moreover, it is advantageous to use small incision methods when performing cataract removal in eyes with concurrent glaucoma to preserve sufficient space should filtration surgery become necessary. Techniques that allow operative enlargement of the pupil for phacoemulsification yet preserve the function and appearance of the pupil are particularly valuable. As surgical experience is gained one may perform endolenticular emulsification without pupillary enlargement. However, for transitional surgeons or in cases with pupils less than 3.5 mm in diameter, it is generally
Presented in part at the Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, March 1990. Figures 2-5, 7, 9-12, 14-17, and Table 1 reprinted from Nordan LT, Maxwell WA , Davison JA, eds, The Surgical Rehabilitation of Vision, New York, Gower Medical Publishing, 1992, with permission of the publisher. Reprint requests to Samuel Masket, M.D., Suite 204, 7230 Medical Center Drive, West Hills, California 91307-1957. 518
J CATARACf REFRACf SURG-VOL 18, SEPTEMBER
1992
Table 1. Traditional methods for pupil enlargement. Synechiolysis Sector iridectomy Inferior/radial sphincterotomies Multiple incomplete sphincterotomies Postplaced suture of iris defects
preferable to enlarge the pupil. One method incorporates the combination of a superior radial full sphincterotomy with preplacement of a superior iris suture, as described by Neuhann and Grabow (Thomas Neuhann, "The Technique of Iridotomy and Iris Suture in Cases of Excessive Miosis"; Harry Grabow, "McCannel Suture Technigue for Phacoemulsification with Foldable IOL Through Miotic Pupil and 4-mm Incision." Welsh Cataract Congress, Houston, November 1988). Preplacement of the permanent iris suture assures proper alignment of the iris pillars and results in a physiologic pupil, as seen in Figures 2 and 3. I have modified the preplaced iris suture method by moving the sphincterotomy inferiorly, to the 6 o'clock position, to enlarge the work space in the inferior aspect of the chamber where most endolenticular or fracture forms of phacoemulsification are generally performed. The superiorly oriented method seems most appropriate for bimanual iris plane phacoemulsification which requires visibility and working space in the superior aspect of the chamber. For current in-the-bag techniques of endolenticular phacoemulsification,
Fig. 1.
(Masket) Postoperative appearance of pupil after five small radial sphincterotomies. Aesthetic appearance is unsatisfactory, particularly in cases with light-colored irides.
Fig. 2.
(Masket) Postoperative appearance of pupil after preplaced suture with superior radial iridotomy. A small notch at the margin of the pupil is evident but not aesthetically significant.
Fig. 3.
(Masket) Eye in Figure 2 after pharmacologic dilation. The pupil appears normal and functions normally.
Fig. 4.
(Masket) The pupil is miotic and has synechias to the anterior lens capsule. Synechiolysis is performed; in certain cases, it may enlarge the pupil sufficiently for cataract surgery.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
519
Fig. 5.
(Masket) After the anterior and posterior chambers are filled with copious amounts of viscoelastic material, a 10-0 polypropylene suture is guided through the inferonasallimbus by an ultrasharp, thin, straight needle (Ethicon STC-6).
Fig. 7.
(Masket) The needle is brought across the chamber to exit at the inferotemporallimbus. Occasionally it is helpful to guide the needle with a blunt instrument passed through a side-port limbal incision. Alternatively, the sharp needle may be retrieved in a fine cannula or needle passed through an inferotemporal limbal puncture.
Fig. 8.
(Masket) The inferior iris is fully transfixed by a single strand of 10-0 polypropylene.
Fig. 9.
(Masket) A microhook is passed through the superior incision and used to loop the suture from the underside of the iris.
however, greater visibility in the inferior aspect of the chamber is required.
TECHNIQUE The inferior sphincterotomy with preplaced suture method is detailed in Figures 4 through 15. As seen in Figure 4, posterior synechias are often noted in cases with miotic pupils; synechiolysis may expand the pupil adequately for surgery. In this case, however, I enlarged the pupil. Suture placement using an ultrasharp, straight, thin (sixwire) needle (Ethicon STC-6) is demonstrated in Figures 5 through 7. To protect the cornea and anterior lens capsule the anterior and posterior
Fig. 6.
520
(Masket) The sharpness of the needle allows easy transfixation of the inferior iris sphincter. The needle has to pass through the full thickness of the iris tissue but not damage the underlying lens capsule.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
chambers are hyperexpanded with a viscoelastic agent prior to suture passage. The completed suture (Figure 8) must be looped to allow for a generous inferior sphincterotomy (Figures 9, 10). The free ends of the suture are then retrieved th.rough an inferior limbal puncture in the manner of a McCannel suture 2 (Figures 11, 12). After continuous circular capsulotomy is completed, nucleus fracture endolenticular phacoemulsification (Figure 13) and cortex removal prepare the eye for lens implantation (Figure 14). The preplaced suture is tied securely at the inferior limbal puncture, the knot cut short, and the iris reposited, completing the surgical method (Figure 15). Fig. 12.
(Masket) The microhook is passed through the inferior limbal opening and used to retrieve one of the free ends of the polypropylene suture. The remaining end is grasped with a tying forceps for stability. After both ends of the suture are brought through the inferior limbal puncture, the free ends are taped to the drapes with a steristrip to prevent accidental traction and dislodgment of the suture.
DISCUSSION The technique described provides one method for maintaining the pupil in cases with preoperative miosis. Postoperatively the pupil functions well, appears normal, and dilates in response to
Fig. 10.
(Masket) While carefully avoiding the looped suture, the inferior iris sphincter is cut with Vannas scissors.
Fig. 13.
(Masket) Phaco and fracture endolenticular phacoemulsification is performed after continuous circular tear anterior capsulotomy.
Fig. 11.
(Masket) A self-sealing inferior limbal incision is created with a supersharp blade.
Fig. 14.
(Masket) After lens emulsification and cortical aspiration, the eye is ready for IOL implantation.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
521
Fig. 15.
(Masket) Following IOL implantation the polypropylene iris suture is tied with moderate traction at the inferior limbal puncture, completing the preplaced suture closure of the inferior iris sphincter, resulting in "normal" pupillary shape.
Fig. 16.
(Masket) Undilated appearance of pupil after the inferior preplaced suture method.
Fig. 17.
(Masket) Dilated view of eye in Figure 16 after pharmacologic dilation. As with the superiorly placed suture method (Figures 2, 3), the pupil appears normal and functions normally.
pharmacologic agents, as seen in Figures 16 and 17. The method may be used for very small pupils; in rare instances both the inferior and superior sphincter may be enlarged with preplaced sutures and sphincterotomies. One possible drawback, however, is the increase in surgical time necessary for placing and positioning the iris suture. Nevertheless, my data suggest an iris suture is essential in maintaining a normal pupil postoperatively and providing adequate work space intraoperatively.3 Methods for managing the poorly dilating pupil must consider these criteria.
REFERENCES 1. Fine IH. Pupilloplasty technique to improve cosme sis and preserve function after cataract surgery. In: Nordan LT, Maxwell WA, Davison JA, eds, The Surgical Rehabilitation of Vision. New York, Gower Medical Publishing, 1992
522
2. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7(2}:98-103 3. Masket S. Relationship between postoperative pupil size and disability glare. J Cataract Refract Surg 1992; 18:506-507
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992