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Another use for a pupil dilating device
LETTERS
Iris-fixated posterior chamber intraocular lenses Kaiura et al.1 report recurrent postoperative ‘‘slippage’’ of the intraocular lens (IOL) as a problem in 3 of their 4 cases of complications arising from iris-fixated posterior chamber IOLs. In all 3 cases, they specifically state that the 10-0 polypropylene peripheral iris sutures remained present, knotted, and intact. In 2 cases, they note that while the haptics remained ‘‘captured’’ by the sutures, inferior IOL dislocation occurred. The authors thought the etiology of the IOL slippage despite intact iris sutures was unclear but mentioned the possibility that the sutures had not been tied tightly enough. In my opinion, this was undoubtedly the problem. The concern for haptic slippage when using simple McCannel sutures, as I strongly suspect was the case here, is indeed addressed in the original description2 of the technique Kaiura et al. used to perform their surgery. While we applaud McCannel for his revolutionary suture idea, many of us now agree that incorporating a Siepser sliding knot appears to provide more secure haptic-to-iris fixation with less iris trauma, making it our preferred tying technique for iris fixation of an IOL in a closed chamber.3–7 Tying the suture ends through a common corneal paracentesis directly above a haptic that is producing countertraction makes cinching the knot difficult at best and can result in a loose suture loop that risks slippage of the haptic. This would account for the findings in Kaiura et al.’s 3 cases. However, Siepser’s modification using 2 opposing paracenteses allows the suture ends to be pulled in opposite directions in the absence of other tractional forces, thereby allowing more precise knot tensioning and locking. In the series reported by Stutzman and Stark,8 McCannel sutures without Siepser’s modification were used and 1 case of haptic dislocation occurred. More recently, we presented our results in 46 eyes that had peripheral iris fixation of a foldable IOL in the absence of capsule support.9 In most of these cases, Siepser’s tying technique was incorporated and we could identify no cases of haptic slippage. Kaiura et al. are to be commended for highlighting this crucial aspect of peripheral iris suture fixation and its potential impact on IOL stability. GARRY P. CONDON, MD Pittsburgh, Pennsylvania, USA REFERENCES 1. Kaiura TL, Seedor JA, Koplin RS, et al. Complications arising from irisfixated posterior chamber intraocular lenses. J Cataract Refract Surg 2005; 31:2420–2422 2. Condon GP. Simplified small-incision peripheral iris fixation of an AcrySof intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1663–1667 3. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7(2):98–103 4. Siepser SB. The closed-chamber slipping suture technique for iris repair. Ann Ophthalmol 1994; 26:3:71–72 5. Condon GP. Peripheral iris fixation of a foldable acrylic posterior chamber intraocular lens in the absence of capsule support. Tech Ophthalmol 2004; 2:104–109 6. Chang DF. Siepser slipknot for McCannel iris-suture fixation of subluxated intraocular lenses. J Cataract Refract Surg 2004; 30:1170–1176
7. Osher RH, Snyder ME, Cionni RJ. Modification of the Siepser slip-knot technique. J Cataract Refract Surg 2005; 31:1098–1100 8. Stutzman RD, Stark WJ. Surgical technique for suture fixation of an acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1658–1662 9. Condon GP, Ahmed IK, Masket S, et al. Small-incision iris fixation of foldable intraocular lenses in the absence of capsule support. In press, Ophthalmology
Another use for a pupil dilating device Auffarth et al.1 describe the use of the Perfect Pupil iris extension system during cataract surgery in eyes with iridoschisis to prevent contact with the iris tissue. I have used a similar device, the Morcher pupil dilator ring type 5S, following iris trauma during phacoemulsification. If the phacoemulsification tip comes in contact with the iris, the resulting damage can present problems similar to those in an eye with iridoschisis. The iris tissue at the site of the trauma shreds and separates into strands, and these strands interfere with the subsequent surgery. The Morcher pupil dilator ring is a semicircular poly(methyl methacrylate) (PMMA) ring similar to the Perfect Pupil system but lacking the integrated arm. The ring provides a mean pupil size of 5.9 mm.2 It has a flanged groove that engages the pupil margin. The ring has 5 tabs with multiple holes that help position the ring in the pupil. It is held vertically, and one of the open ends of the semicircle is fed into the wound. The ring is then laid flat and dialed into the anterior chamber under an ophthalmic viscosurgical device (OVD). The tab directly opposite the opening is engaged with the pupil, and 2 Sinskey hooks are used to engage the holes and manipulate the ring into position. In my case, the eye had a small, poorly dilating pupil of 4.0 mm. Initially, I decided not to use a pupil dilating device but to dilate the pupil with an OVD. The capsulorhexis was uneventful, but the pupil margin was traumatized during nucleus sculpting. This resulted in iris strands, which made further phacoemulsification difficult because the strands were aspirated into the handpiece port. The pupil dilator was inserted through the main incision, and the iris strands were trapped by the flange, which helped keep the strands of the damaged iris away from the instrument tip. The PMMA flange also protected the pupil from further damage, and the remainder of the procedure was uneventful. The iris strands were cut flush with the pupil margin following lens implantation and explantation of the pupil dilator. It seems logical to think the Perfect Pupil system could also be used in this situation as it is similar in construction. KRISHNAMOORTHY NARAYANAN, FRCSED Newcastle upon Tyne, United Kingdom REFERENCES 1. Auffarth GU, Reuland AJ, Heger T, Vo¨lcker HE. Cataract surgery in eyes with iridoschisis using the Perfect Pupil iris extension system. J Cataract Refract Surg 2005; 31:1877–1880 2. Akman A, Yilmaz G, Oto S, Akova YA. Comparison of various pupil dilatation methods for phacoemulsification in eyes with a small pupil secondary to pseudoexfoliation. Ophthalmology 2004; 111:1693–1698
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Iris-fixated posterior chamber intraocular lenses Kaiura et al.1 report recurrent postoperative ‘‘slippage’’ of the intraocular lens (IOL) as a problem in 3 of their 4 cases of complications arising from iris-fixated posterior chamber IOLs. In all 3 cases, they specifically state that the 10-0 polypropylene peripheral iris sutures remained present, knotted, and intact. In 2 cases, they note that while the haptics remained ‘‘captured’’ by the sutures, inferior IOL dislocation occurred. The authors thought the etiology of the IOL slippage despite intact iris sutures was unclear but mentioned the possibility that the sutures had not been tied tightly enough. In my opinion, this was undoubtedly the problem. The concern for haptic slippage when using simple McCannel sutures, as I strongly suspect was the case here, is indeed addressed in the original description2 of the technique Kaiura et al. used to perform their surgery. While we applaud McCannel for his revolutionary suture idea, many of us now agree that incorporating a Siepser sliding knot appears to provide more secure haptic-to-iris fixation with less iris trauma, making it our preferred tying technique for iris fixation of an IOL in a closed chamber.3–7 Tying the suture ends through a common corneal paracentesis directly above a haptic that is producing countertraction makes cinching the knot difficult at best and can result in a loose suture loop that risks slippage of the haptic. This would account for the findings in Kaiura et al.’s 3 cases. However, Siepser’s modification using 2 opposing paracenteses allows the suture ends to be pulled in opposite directions in the absence of other tractional forces, thereby allowing more precise knot tensioning and locking. In the series reported by Stutzman and Stark,8 McCannel sutures without Siepser’s modification were used and 1 case of haptic dislocation occurred. More recently, we presented our results in 46 eyes that had peripheral iris fixation of a foldable IOL in the absence of capsule support.9 In most of these cases, Siepser’s tying technique was incorporated and we could identify no cases of haptic slippage. Kaiura et al. are to be commended for highlighting this crucial aspect of peripheral iris suture fixation and its potential impact on IOL stability. GARRY P. CONDON, MD Pittsburgh, Pennsylvania, USA REFERENCES 1. Kaiura TL, Seedor JA, Koplin RS, et al. Complications arising from irisfixated posterior chamber intraocular lenses. J Cataract Refract Surg 2005; 31:2420–2422 2. Condon GP. Simplified small-incision peripheral iris fixation of an AcrySof intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1663–1667 3. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7(2):98–103 4. Siepser SB. The closed-chamber slipping suture technique for iris repair. Ann Ophthalmol 1994; 26:3:71–72 5. Condon GP. Peripheral iris fixation of a foldable acrylic posterior chamber intraocular lens in the absence of capsule support. Tech Ophthalmol 2004; 2:104–109 6. Chang DF. Siepser slipknot for McCannel iris-suture fixation of subluxated intraocular lenses. J Cataract Refract Surg 2004; 30:1170–1176
7. Osher RH, Snyder ME, Cionni RJ. Modification of the Siepser slip-knot technique. J Cataract Refract Surg 2005; 31:1098–1100 8. Stutzman RD, Stark WJ. Surgical technique for suture fixation of an acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1658–1662 9. Condon GP, Ahmed IK, Masket S, et al. Small-incision iris fixation of foldable intraocular lenses in the absence of capsule support. In press, Ophthalmology
Another use for a pupil dilating device Auffarth et al.1 describe the use of the Perfect Pupil iris extension system during cataract surgery in eyes with iridoschisis to prevent contact with the iris tissue. I have used a similar device, the Morcher pupil dilator ring type 5S, following iris trauma during phacoemulsification. If the phacoemulsification tip comes in contact with the iris, the resulting damage can present problems similar to those in an eye with iridoschisis. The iris tissue at the site of the trauma shreds and separates into strands, and these strands interfere with the subsequent surgery. The Morcher pupil dilator ring is a semicircular poly(methyl methacrylate) (PMMA) ring similar to the Perfect Pupil system but lacking the integrated arm. The ring provides a mean pupil size of 5.9 mm.2 It has a flanged groove that engages the pupil margin. The ring has 5 tabs with multiple holes that help position the ring in the pupil. It is held vertically, and one of the open ends of the semicircle is fed into the wound. The ring is then laid flat and dialed into the anterior chamber under an ophthalmic viscosurgical device (OVD). The tab directly opposite the opening is engaged with the pupil, and 2 Sinskey hooks are used to engage the holes and manipulate the ring into position. In my case, the eye had a small, poorly dilating pupil of 4.0 mm. Initially, I decided not to use a pupil dilating device but to dilate the pupil with an OVD. The capsulorhexis was uneventful, but the pupil margin was traumatized during nucleus sculpting. This resulted in iris strands, which made further phacoemulsification difficult because the strands were aspirated into the handpiece port. The pupil dilator was inserted through the main incision, and the iris strands were trapped by the flange, which helped keep the strands of the damaged iris away from the instrument tip. The PMMA flange also protected the pupil from further damage, and the remainder of the procedure was uneventful. The iris strands were cut flush with the pupil margin following lens implantation and explantation of the pupil dilator. It seems logical to think the Perfect Pupil system could also be used in this situation as it is similar in construction. KRISHNAMOORTHY NARAYANAN, FRCSED Newcastle upon Tyne, United Kingdom REFERENCES 1. Auffarth GU, Reuland AJ, Heger T, Vo¨lcker HE. Cataract surgery in eyes with iridoschisis using the Perfect Pupil iris extension system. J Cataract Refract Surg 2005; 31:1877–1880 2. Akman A, Yilmaz G, Oto S, Akova YA. Comparison of various pupil dilatation methods for phacoemulsification in eyes with a small pupil secondary to pseudoexfoliation. Ophthalmology 2004; 111:1693–1698
J CATARACT REFRACT SURG - VOL 32, SEPTEMBER 2006
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