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A technique for repair of iridodialysis in children
A Technique for Repair of Iridodialysis in Children Sandra M. Brown, M D
Iridodialysis can occur with blunt or penetrating trauma or inadvertently during intraocular surgery. A small dialysis may not need treatment. A larger iridodialysis that causes polycoria and diplopia, or a grossly eccentric pupil, needs to be reapproximated. A number of surgical techniques for repair, using double-armed polypropylene suture, have been reported. The suture is either left external on the surface of the sclera with the knot buried, I,2 covered with a triangular scleral flap, 3-5 or retrieved with special forceps and buried in a scleral "groove. ''6 These techniques have also been used to allow posterior fixation of intraocular lens implants in the absence of capsular support; a complication of this approach is suture erosion through sclera, conjunctiva, or b o t h ] T h e pediatric sclera is softer and more elastic than adult sclera, and surgical repairs must last for decades. Concern about late suture erosion, and a desire for minimal scleral manipulation, led me to develop a simple technique for iridodialysis repair using a scleral tunnel incision and double-armed 10-0 polypropylene suture. TECHNIQUE A corneal paracentesis is made 180 degrees away from the center of the iridodialysis. The anterior chamber is deepened with viscoelastic. The iris is freed of any adhesions to the lens or cornea using a cyclodialysis spatula. The locations for the scleral exits of the polypropylene suture are chosen; more than one tunnel may be necessary if the dialysis is large. A limbal conjunctival peritomy is created to expose sclera at the chosen locations; because of the anticipated posterior exit of the needles through the iris base, it is easier to achieve adequate posterior exposure with one large peritomy rather than multiple small peritomies. A scleral tunnel is created using the Beaver #6600 angled round blade or equivalent. The nmnel is initiated with a perpendicular incision of one-half scleral thickness, From the Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Cente~ Lubbock, Texas. Submitted December 22, 199Z Revision accepted March 27, 1998. J AAPOS 1998;2:380-2. Reprint requests: Sandra M. Brown, MD, Department of Ophthalmology and Visual Sciences, Texas Tecb University Health Soiences Centeg Sixth and Flint, Lubbock, TX 79430. Copyright © 1998 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/98 $5.00 + 0 75/1/93490
380
December1998
3 to 4 mm in length, located 4 to 5 mm posterior to the limbus. The angled blade is used to bevel anteriorly 3 to 4 mm, in the same fashion as for the creation of a phacoemulsification incision. However, the nmnel stops short of the limbus (Figure 1, A). No entry into the anterior chamber is made through this incision. One needle of the double-armed 10-0 polypropylene suture is passed through the paracentesis and engages the torn iris peripherally. The needle is passed through sclera so that it exits deep in the scleral tunnel (ie, anteriorly), ' near one side of the tunnel. The posterior lip of the scleral tunnel can be dimpled with a forceps to aid needle passage. The second needle is passed in the same fashion, exiting at the opposite side of the scleral tunnel (Figure 1, B). The suture is drawn up so that the iris is approximated to the iris base, the needles are cut off, and the suture is tied with a two-one square knot to minimize knot size. Sclera is then closed with 1 or 2 interrupted sutures of the surgeon's preference (Figure 1, C). The size and location of the tunnel allow for some variability in needle exit without compromising the cosmetic appearance of the iris or the scleral coverage of the knot. The conjunctiva is closed with absorbable suture or cautery. I found the Ethicon #1713 suture to be the easiest suture to use (Ethicon, Somerville, NJ). This is an 8-inch double-armed 10-0 prolene suture with the STC-6 plus needle. The needle has no curvature and is 16 mm from tip to swedge and round in cross-section, except at the tip where it has a small flat spatula. The spatula engages the iris readily, and the needle is long enough that it reaches across the anterior chamber, remembering that the total needle pass will be greater in length than the corneal diameter because the needle will exit 2 to 3 mm posterior to the limbus. An alternative double-armed 10-0 prolene suture is the Ethicon #788G. This needle (CIF-4) has a slight curvature with a chord length of 13 mm. It is a point-down cutting needle, which may be undesirable if the lens is clear because the cutting face of the needle can lacerate the anterior capsule.
CASE R E P O R T A 10-year-old boy struck himself in the right eye with a tent peg while camping. He sustained a temporal corneoscleral laceration, which was repaired by the referring physician. On presentation 2 days later, visual examination showed light perception with projection in the right eye and 20/20 vision in the left eye. In addition to the lacera-
Journal of AAPOS
Journal of AAPOS Volume 2 Number 6 December 1998
B~'OTVI~ 381
A
B
C FIG 1. A, Detail for scleral incision, side view. Tunnel overlies iris root. R, Detail for needle passage, top view. C, Detail for final appearance of repair, top view. Scleral incisions are closed with 1 or 2 sutures.
don, there was a 4 clock-hour temporal iridodialysis with complete rupture through the sphincter at the 11 o'clock position (Figure 2, A). The anterior lens capsule was open superiorly, and flocculent lens cortex protruded into the anterior chamber. After several weeks of management with topical antibiotics and intensive topical steroids the patient underwent iridodialysis repair, cataract extraction, and posterior chamber lens implantation in one session. The iridodialysis was repaired using two separate tunnels, one centered at an 8 o'clock position and one at 9:30 (inferior to the scleral portion of the laceration) (Figure 2, B). Despite
Fill 2. A, Slit lamp photograph of right eye after repair of corneoscleral laceration. B, Slit lamp photograph of right eye after repair of iridodialysis, cataract extraction and lens implantation. Note superotemporal peripheral anterior synechiae with updrawn pupil (star). C, Slit lamp photograph of right eye after liberation of superior synechiae, posterior capsulectomy, and modest inferior pupilloplasty. Pupil shows improved centration superiorly with less tension on temporal iris (star).
intensive oral and topical steroids, extensive anterior synechiae formed, which necessitated a third procedure to liberate superior iris and improve pupil centration (Figure 2, C). Traction was applied to the iris base when sweeping
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Journal of AAPOS Volume 2 Number 6 December 1998
Brown
recalcitrant synechiae with the cyclodialysis spatula, but the iridodialysis repair held. After this surgery, the blue prolene sutures became faintly visible in the beds of the scleral tunnels, which I believe is a result of scleral thinning from the prolonged oral and topical steroid use. Four months after the operation, the patient's corrected vision is 20/30, and there has been no erosion of the prolene sutures.
dialysis, including iris and ciliary body hemorrhage, lens capsule laceration, formation of peripheral anterior synechiae with late pupil displacement and angle closure, and infection, are neither increased nor decreased by modifying the scleral approach. Careful long-term follow-up is still necessary to detect erosion or other complications of the initial injury, including cataract and glaucoma. References
DISCUSSION
The scleral tunnel incision is in widespread use for phacoemulsification. The wound architecture is resilient during surgical manipulation, should induce little astigmatism, and can be created by one of several available styles of angled surgical blades. This incision can be readily adapted to the repair of an iridodialysis. The advantages of the scleral tunnel incision for repair of iridodialyses in patients of all ages include ease of creation without the need to elevate a scleral flap; complete coverage of the nonabsorbable polypropylene suture and knot; and wound stability in the case of eye-rubbing or blunt trauma after operation. Theoretically, this technique might minimize the likelihood of late suture erosion by providing good initial coverage with minimal scleral manipulation. The well-known risks of repairing an irido-
1. Kaufman SC, Insler MS. Surgical repair of a traumatic iridodialysis. Ophthalmic Surg Lasers 1996;27:963-6. 2. Wachler BB, Krueger RR. Double-armed McCannell suture for repair of traumatic iridodialysis.AmJ Ophthalmol 1996;122:109-10. 3. Kervick GN, Johnston SS. Repair of inferior iridodialysis using a partial-thickness scleral flap. Ophthalmic Surg Lasers 1991;22: 354-5.
4. Nunziata BR. Repair of iridodialysis using a 17-millimeter straight needle. Ophthalmic Surg Lasers 1993;24:627-9. 5. Zeiter JH, Shin DH, Shi DX. A dosed chamber technique for repair of iridodialysis. Ophthalmic Surg Lasers 1993;24:476-80. 6. Chang S, Coll GE. Surgical techniques for repositioning a dislocated intraocnlar lens, repair of iridodialysis, and secondaryintraocular lens implantation using innovative 25-gauge forceps. Am J Ophthalmol 1995;119:165-74. 7. Solomon K, Gussler JR, Gussler C, Van_MeterWS. Incidence and management of complications of transscIerally sutured posterior chamber lenses.J Cataract Refract Surg 1993;19:488-93.
Iridodialysis can occur with blunt or penetrating trauma or inadvertently during intraocular surgery. A small dialysis may not need treatment. A larger iridodialysis that causes polycoria and diplopia, or a grossly eccentric pupil, needs to be reapproximated. A number of surgical techniques for repair, using double-armed polypropylene suture, have been reported. The suture is either left external on the surface of the sclera with the knot buried, I,2 covered with a triangular scleral flap, 3-5 or retrieved with special forceps and buried in a scleral "groove. ''6 These techniques have also been used to allow posterior fixation of intraocular lens implants in the absence of capsular support; a complication of this approach is suture erosion through sclera, conjunctiva, or b o t h ] T h e pediatric sclera is softer and more elastic than adult sclera, and surgical repairs must last for decades. Concern about late suture erosion, and a desire for minimal scleral manipulation, led me to develop a simple technique for iridodialysis repair using a scleral tunnel incision and double-armed 10-0 polypropylene suture. TECHNIQUE A corneal paracentesis is made 180 degrees away from the center of the iridodialysis. The anterior chamber is deepened with viscoelastic. The iris is freed of any adhesions to the lens or cornea using a cyclodialysis spatula. The locations for the scleral exits of the polypropylene suture are chosen; more than one tunnel may be necessary if the dialysis is large. A limbal conjunctival peritomy is created to expose sclera at the chosen locations; because of the anticipated posterior exit of the needles through the iris base, it is easier to achieve adequate posterior exposure with one large peritomy rather than multiple small peritomies. A scleral tunnel is created using the Beaver #6600 angled round blade or equivalent. The nmnel is initiated with a perpendicular incision of one-half scleral thickness, From the Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Cente~ Lubbock, Texas. Submitted December 22, 199Z Revision accepted March 27, 1998. J AAPOS 1998;2:380-2. Reprint requests: Sandra M. Brown, MD, Department of Ophthalmology and Visual Sciences, Texas Tecb University Health Soiences Centeg Sixth and Flint, Lubbock, TX 79430. Copyright © 1998 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/98 $5.00 + 0 75/1/93490
380
December1998
3 to 4 mm in length, located 4 to 5 mm posterior to the limbus. The angled blade is used to bevel anteriorly 3 to 4 mm, in the same fashion as for the creation of a phacoemulsification incision. However, the nmnel stops short of the limbus (Figure 1, A). No entry into the anterior chamber is made through this incision. One needle of the double-armed 10-0 polypropylene suture is passed through the paracentesis and engages the torn iris peripherally. The needle is passed through sclera so that it exits deep in the scleral tunnel (ie, anteriorly), ' near one side of the tunnel. The posterior lip of the scleral tunnel can be dimpled with a forceps to aid needle passage. The second needle is passed in the same fashion, exiting at the opposite side of the scleral tunnel (Figure 1, B). The suture is drawn up so that the iris is approximated to the iris base, the needles are cut off, and the suture is tied with a two-one square knot to minimize knot size. Sclera is then closed with 1 or 2 interrupted sutures of the surgeon's preference (Figure 1, C). The size and location of the tunnel allow for some variability in needle exit without compromising the cosmetic appearance of the iris or the scleral coverage of the knot. The conjunctiva is closed with absorbable suture or cautery. I found the Ethicon #1713 suture to be the easiest suture to use (Ethicon, Somerville, NJ). This is an 8-inch double-armed 10-0 prolene suture with the STC-6 plus needle. The needle has no curvature and is 16 mm from tip to swedge and round in cross-section, except at the tip where it has a small flat spatula. The spatula engages the iris readily, and the needle is long enough that it reaches across the anterior chamber, remembering that the total needle pass will be greater in length than the corneal diameter because the needle will exit 2 to 3 mm posterior to the limbus. An alternative double-armed 10-0 prolene suture is the Ethicon #788G. This needle (CIF-4) has a slight curvature with a chord length of 13 mm. It is a point-down cutting needle, which may be undesirable if the lens is clear because the cutting face of the needle can lacerate the anterior capsule.
CASE R E P O R T A 10-year-old boy struck himself in the right eye with a tent peg while camping. He sustained a temporal corneoscleral laceration, which was repaired by the referring physician. On presentation 2 days later, visual examination showed light perception with projection in the right eye and 20/20 vision in the left eye. In addition to the lacera-
Journal of AAPOS
Journal of AAPOS Volume 2 Number 6 December 1998
B~'OTVI~ 381
A
B
C FIG 1. A, Detail for scleral incision, side view. Tunnel overlies iris root. R, Detail for needle passage, top view. C, Detail for final appearance of repair, top view. Scleral incisions are closed with 1 or 2 sutures.
don, there was a 4 clock-hour temporal iridodialysis with complete rupture through the sphincter at the 11 o'clock position (Figure 2, A). The anterior lens capsule was open superiorly, and flocculent lens cortex protruded into the anterior chamber. After several weeks of management with topical antibiotics and intensive topical steroids the patient underwent iridodialysis repair, cataract extraction, and posterior chamber lens implantation in one session. The iridodialysis was repaired using two separate tunnels, one centered at an 8 o'clock position and one at 9:30 (inferior to the scleral portion of the laceration) (Figure 2, B). Despite
Fill 2. A, Slit lamp photograph of right eye after repair of corneoscleral laceration. B, Slit lamp photograph of right eye after repair of iridodialysis, cataract extraction and lens implantation. Note superotemporal peripheral anterior synechiae with updrawn pupil (star). C, Slit lamp photograph of right eye after liberation of superior synechiae, posterior capsulectomy, and modest inferior pupilloplasty. Pupil shows improved centration superiorly with less tension on temporal iris (star).
intensive oral and topical steroids, extensive anterior synechiae formed, which necessitated a third procedure to liberate superior iris and improve pupil centration (Figure 2, C). Traction was applied to the iris base when sweeping
382
Journal of AAPOS Volume 2 Number 6 December 1998
Brown
recalcitrant synechiae with the cyclodialysis spatula, but the iridodialysis repair held. After this surgery, the blue prolene sutures became faintly visible in the beds of the scleral tunnels, which I believe is a result of scleral thinning from the prolonged oral and topical steroid use. Four months after the operation, the patient's corrected vision is 20/30, and there has been no erosion of the prolene sutures.
dialysis, including iris and ciliary body hemorrhage, lens capsule laceration, formation of peripheral anterior synechiae with late pupil displacement and angle closure, and infection, are neither increased nor decreased by modifying the scleral approach. Careful long-term follow-up is still necessary to detect erosion or other complications of the initial injury, including cataract and glaucoma. References
DISCUSSION
The scleral tunnel incision is in widespread use for phacoemulsification. The wound architecture is resilient during surgical manipulation, should induce little astigmatism, and can be created by one of several available styles of angled surgical blades. This incision can be readily adapted to the repair of an iridodialysis. The advantages of the scleral tunnel incision for repair of iridodialyses in patients of all ages include ease of creation without the need to elevate a scleral flap; complete coverage of the nonabsorbable polypropylene suture and knot; and wound stability in the case of eye-rubbing or blunt trauma after operation. Theoretically, this technique might minimize the likelihood of late suture erosion by providing good initial coverage with minimal scleral manipulation. The well-known risks of repairing an irido-
1. Kaufman SC, Insler MS. Surgical repair of a traumatic iridodialysis. Ophthalmic Surg Lasers 1996;27:963-6. 2. Wachler BB, Krueger RR. Double-armed McCannell suture for repair of traumatic iridodialysis.AmJ Ophthalmol 1996;122:109-10. 3. Kervick GN, Johnston SS. Repair of inferior iridodialysis using a partial-thickness scleral flap. Ophthalmic Surg Lasers 1991;22: 354-5.
4. Nunziata BR. Repair of iridodialysis using a 17-millimeter straight needle. Ophthalmic Surg Lasers 1993;24:627-9. 5. Zeiter JH, Shin DH, Shi DX. A dosed chamber technique for repair of iridodialysis. Ophthalmic Surg Lasers 1993;24:476-80. 6. Chang S, Coll GE. Surgical techniques for repositioning a dislocated intraocnlar lens, repair of iridodialysis, and secondaryintraocular lens implantation using innovative 25-gauge forceps. Am J Ophthalmol 1995;119:165-74. 7. Solomon K, Gussler JR, Gussler C, Van_MeterWS. Incidence and management of complications of transscIerally sutured posterior chamber lenses.J Cataract Refract Surg 1993;19:488-93.