- Email: [email protected]
Repairing iridodialysis by riveting with a double-flanged polypropylene suture
1531
TECHNIQUE
Repairing iridodialysis by riveting with a double-flanged polypropylene suture Mami Kusaka, MD, Naomi Miyamoto, MD, Masayuki Akimoto, MD, PhD
Three patients with iridodialysis were recruited. A 6-0 polypropylene suture was cut to the proper length and flanged by cautery. A long (19.0 mm), ultrathin 30-gauge needle was inserted in the anterior chamber from the sclera around the iris and penetrated in the dialyzed iris, then exited through the cornea on the contralateral side. The flanged polypropylene suture was inserted in the needle from the unflanged side. After the 30gauge needle was withdrawn, the flanged suture remained, passing the dialyzed iris and sclera. The unflanged ends of the
T
raumas, including surgery, can cause iridodialysis (Figure 1). Deviation of the pupil occurs and causes blurred vision and photopsia. To date, the repair of iridodialysis had been difficult because of the softness and flexibility of the iris as well as the narrow surgical space between the cornea and lens; furthermore, the needle has to be moved back and forth.1–3 In other medical fields, for example, a surgical stapler, which is a knotless clipping technique, has replaced the suturing technique.4 We found that polypropylene suture can be flanged by heat and used in the process of intrascleral intraocular lens (IOL) fixation.5 Thus, we assessed the application of double-flanged sutures as rivets to repair iridodialysis. To do this, we recruited three patients with iridodialysis. The causes of iridodialysis were previous surgery and trauma. The procedures were performed according to the Declaration of Helsinki, and they were approved by the hospital’s ethics committee. Written informed consent was obtained. SURGICAL TECHNIQUE A 6-0 polypropylene suture is prepared in advance. The diameter of this suture is three times that of a 10-0 polypropylene suture, but it is less than that of the IOL haptic. Approximately 3.0 cm of the polypropylene suture is reduced into a small ball with heat applied using hightemperature cautery (Accu-Temp, Beaver-Visitec
polypropylene sutures were cut and flanged until each flange reached the sclera. It was easy to place multiple sutures. There were no cases of extrusion of the suture nor of the recurrence of iridodialysis up to 1 year. This technique is a good alternative to repair iridodialysis. J Cataract Refract Surg 2019; 45:1531–1534 Q 2019 ASCRS and ESCRS Online Video
International, Inc.) (Figure 1, A). The ball is then flattened and widened with a needle holder (Figure 1, B). The polypropylene suture is cut to reach a length of approximately 5.0 cm. The anterior chamber is filled with sodium hyaluronate 1% (Opegan Hi) ophthalmic viscosurgical device. A 19.0 mm long, ultrathin 30-gauge needle is inserted parallel to the iris in the anterior chamber of the eye from the sclera 2.0 mm posterior to the limbus and penetrated in the iris using forceps (Figure 1, C). This needle is then directed to exit the globe using a 27-gauge needle as the guide (Figure 1, D). The modified polypropylene suture is inserted in the 30-gauge needle, and the needle is removed (Figure 1, E and F). The polypropylene suture penetrating the iris is retained in the anterior chamber. In cases of wide dialysis, the same procedure is repeated until the repair is complete. The length of each polypropylene suture is adjusted based on the shape of the iris. The polypropylene sutures are then cut (Figure 1, G). Each end of the suture is flanged and shortened using high-temperature cautery until the flange reaches the sclera (Figure 1, H). The flanges are not buried in the sclera. Video 1 (available at http: //jcrsjournal.org) demonstrates the representative procedure. DISCUSSION There were no surgery-associated complications in any of the cases. We observed that the polypropylene not only
Submitted: March 15, 2019 | Final revision submitted: June 13, 2019 | Accepted: August 1, 2019 From the Ophthalmology Department, Osaka Red Cross Hospital, Osaka, Japan. Corresponding author: Masayuki Akimoto, MD, PhD, Ophthalmology Department, Osaka Red Cross Hospital, Osaka Red Cross Hospital, 5-30 Fudegasakicho, Tennojiku, Osaka 543-8555, Japan. Email: [email protected]. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2019.08.001
1532
TECHNIQUE: IRIDODIALYSIS REPAIR BY DOUBLE-FLANGED SUTURES AS RIVETS
Figure 1. Repairing iridodialysis with a new technique. A: Measure approximately 3.0 cm of the polypropylene suture and modify it using the heat of hightemperature cautery. B: Press the flange with the needle holder and make it flat and wide. C: Penetrate the iris while holding the flange with the tweezers. D: Lead the thinner needle to the outside of the globe using a 27-gauge needle as the guide. E: Insert the modified polypropylene suture in the thinner 30-gauge needle. F: Withdraw the needle. G: After arranging the shape of the iris, cut the polypropylene. H: Modify using hightemperature cautery until the flange reaches the sclera.
dislocated the atrophic iris but also fixed and retained its shape (Figure 2). There is little possibility of the rivets falling out in the long term because they were thicker than 10-0 polypropylene; however, some risk does exist. In cases of shorter iridodialysis, which require just one stich to be fixed, a double-armed suture is still useful; however, our technique is more useful for cases with wide iridodialysis, which need to be sutured more than once because the needle is moved in only one way, it is not necessary to make a loop, and a single suture can be used for several stiches in the same one-way technique (Figures 3 and 4). It is, however, concerning that the edge will be exposed on the conjunctiva because it is left exposed on the sclera. Haptic exposure is a rare complication after intrascleral fixation. It happens partly because the IOL haptic is long and mechanically connected with the optic. It is
Volume 45 Issue 11 November 2019
possible that outward counterforce on the haptics can arise by rubbing the eye. Suture exposure after IOL suturing is also an issue. It is because the sharpness of the end of the 10-0 polypropylene suture. On the other hand, in our case series, the suture was cut very short, the iris exerted no outward force on the suture, and the tip was round by heat. Therefore, continued follow-up will be required for all cases, although we have not noted its exposure on the conjunctiva in any case up to 1 year (Figure 5). The technique to repair a traumatic or surgical wound by pinching the tissue, such as with a surgical stapler, rather than suturing it is used in digestive organ surgeries.4 In ophthalmology, riveting has been attempted for retinal detachment,6 but there has been little success. We speculated whether pinching the tissue would be effective with
TECHNIQUE: IRIDODIALYSIS REPAIR BY DOUBLE-FLANGED SUTURES AS RIVETS
1533
Figure 2. Comparison of the shapes of the iris before and after the surgery. A and B: Preoperatively before mydriasis. C: Preoperatively after mydriasis. A0 , B0 , and C0 : Postoperative photographs of the same eyes, respectively.
a modified polypropylene suture depending on the situation. We named this technique of pinching the tissue using modified 6-0 polypropylene suture as “riveting.” Herein, we
reported on iridodialysis; however, we believe this technique can be applied to other surgeries, such as ciliary body dialysis and IOL fixation.
Figure 3. Schemas of the conventional method (A) and the new technique (B).
Figure 4. The case of wide iridodialysis. A: The conventional method. B: The new technique.
Volume 45 Issue 11 November 2019
1534
TECHNIQUE: IRIDODIALYSIS REPAIR BY DOUBLE-FLANGED SUTURES AS RIVETS
Figure 5. Photographs taken after the surgery. A: There is no exposure on the conjunctiva. B: The flange using the gonio lens can be seen.
REFERENCES WHAT WAS KNOWN The repair of iridodialysis is difficult because of the softness and flexibility of the iris, and because of the narrow surgical space between the cornea and the lens. It is also difficult because the needle has to be moved back and forth. In other fields, a knotless clipping technique is replacing the suturing technique.
WHAT THIS PAPER ADDS Noting that the polypropylene suture can be flanged by heat and used in the process of intrascleral intraocular lens fixation, double-flanged sutures were applied as rivets to repair iridodialysis. This technique can be useful for wide iridodialysis, which must be sutured more than once, because the needle is moved in only one way and it is not necessary to make a loop.
Volume 45 Issue 11 November 2019
1. Okamoto Y, Yamada S, Akimoto M. Suturing repair of subtotal iridodialysis. Int Ophthalmol 2018; 38:395–398 2. Voykov B. Knotless technique for iridodialysis repair. Clin Exp Ophthalmol 2016; 44:135–136 3. Snyder ME, Lindsell LB. Nonappositional repair of iridodialysis. J Cataract Refract Surg 2011; 37:625–628 4. Iavazzo C, Gkegkes ID, Vouloumanou EK, Mamais I, Peppas G, Falagas ME. Sutures versus staples for the management of surgical wounds: a metaanalysis of randomized controlled trials. Am Surg 2011; 77:1206–1221 5. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Opthalmology 2017; 124:1136–1142 6. de Juan E Jr, Hickingbotham D, Machemer R. Retinal tacks. Am J Ophthalmol 1985; 99:272–274
Disclosures: Dr. Akimoto is a consultant to Kowa Co. Ltd. None of the authors has a financial or proprietary interest in any material or method mentioned.
TECHNIQUE
Repairing iridodialysis by riveting with a double-flanged polypropylene suture Mami Kusaka, MD, Naomi Miyamoto, MD, Masayuki Akimoto, MD, PhD
Three patients with iridodialysis were recruited. A 6-0 polypropylene suture was cut to the proper length and flanged by cautery. A long (19.0 mm), ultrathin 30-gauge needle was inserted in the anterior chamber from the sclera around the iris and penetrated in the dialyzed iris, then exited through the cornea on the contralateral side. The flanged polypropylene suture was inserted in the needle from the unflanged side. After the 30gauge needle was withdrawn, the flanged suture remained, passing the dialyzed iris and sclera. The unflanged ends of the
T
raumas, including surgery, can cause iridodialysis (Figure 1). Deviation of the pupil occurs and causes blurred vision and photopsia. To date, the repair of iridodialysis had been difficult because of the softness and flexibility of the iris as well as the narrow surgical space between the cornea and lens; furthermore, the needle has to be moved back and forth.1–3 In other medical fields, for example, a surgical stapler, which is a knotless clipping technique, has replaced the suturing technique.4 We found that polypropylene suture can be flanged by heat and used in the process of intrascleral intraocular lens (IOL) fixation.5 Thus, we assessed the application of double-flanged sutures as rivets to repair iridodialysis. To do this, we recruited three patients with iridodialysis. The causes of iridodialysis were previous surgery and trauma. The procedures were performed according to the Declaration of Helsinki, and they were approved by the hospital’s ethics committee. Written informed consent was obtained. SURGICAL TECHNIQUE A 6-0 polypropylene suture is prepared in advance. The diameter of this suture is three times that of a 10-0 polypropylene suture, but it is less than that of the IOL haptic. Approximately 3.0 cm of the polypropylene suture is reduced into a small ball with heat applied using hightemperature cautery (Accu-Temp, Beaver-Visitec
polypropylene sutures were cut and flanged until each flange reached the sclera. It was easy to place multiple sutures. There were no cases of extrusion of the suture nor of the recurrence of iridodialysis up to 1 year. This technique is a good alternative to repair iridodialysis. J Cataract Refract Surg 2019; 45:1531–1534 Q 2019 ASCRS and ESCRS Online Video
International, Inc.) (Figure 1, A). The ball is then flattened and widened with a needle holder (Figure 1, B). The polypropylene suture is cut to reach a length of approximately 5.0 cm. The anterior chamber is filled with sodium hyaluronate 1% (Opegan Hi) ophthalmic viscosurgical device. A 19.0 mm long, ultrathin 30-gauge needle is inserted parallel to the iris in the anterior chamber of the eye from the sclera 2.0 mm posterior to the limbus and penetrated in the iris using forceps (Figure 1, C). This needle is then directed to exit the globe using a 27-gauge needle as the guide (Figure 1, D). The modified polypropylene suture is inserted in the 30-gauge needle, and the needle is removed (Figure 1, E and F). The polypropylene suture penetrating the iris is retained in the anterior chamber. In cases of wide dialysis, the same procedure is repeated until the repair is complete. The length of each polypropylene suture is adjusted based on the shape of the iris. The polypropylene sutures are then cut (Figure 1, G). Each end of the suture is flanged and shortened using high-temperature cautery until the flange reaches the sclera (Figure 1, H). The flanges are not buried in the sclera. Video 1 (available at http: //jcrsjournal.org) demonstrates the representative procedure. DISCUSSION There were no surgery-associated complications in any of the cases. We observed that the polypropylene not only
Submitted: March 15, 2019 | Final revision submitted: June 13, 2019 | Accepted: August 1, 2019 From the Ophthalmology Department, Osaka Red Cross Hospital, Osaka, Japan. Corresponding author: Masayuki Akimoto, MD, PhD, Ophthalmology Department, Osaka Red Cross Hospital, Osaka Red Cross Hospital, 5-30 Fudegasakicho, Tennojiku, Osaka 543-8555, Japan. Email: [email protected]. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2019.08.001
1532
TECHNIQUE: IRIDODIALYSIS REPAIR BY DOUBLE-FLANGED SUTURES AS RIVETS
Figure 1. Repairing iridodialysis with a new technique. A: Measure approximately 3.0 cm of the polypropylene suture and modify it using the heat of hightemperature cautery. B: Press the flange with the needle holder and make it flat and wide. C: Penetrate the iris while holding the flange with the tweezers. D: Lead the thinner needle to the outside of the globe using a 27-gauge needle as the guide. E: Insert the modified polypropylene suture in the thinner 30-gauge needle. F: Withdraw the needle. G: After arranging the shape of the iris, cut the polypropylene. H: Modify using hightemperature cautery until the flange reaches the sclera.
dislocated the atrophic iris but also fixed and retained its shape (Figure 2). There is little possibility of the rivets falling out in the long term because they were thicker than 10-0 polypropylene; however, some risk does exist. In cases of shorter iridodialysis, which require just one stich to be fixed, a double-armed suture is still useful; however, our technique is more useful for cases with wide iridodialysis, which need to be sutured more than once because the needle is moved in only one way, it is not necessary to make a loop, and a single suture can be used for several stiches in the same one-way technique (Figures 3 and 4). It is, however, concerning that the edge will be exposed on the conjunctiva because it is left exposed on the sclera. Haptic exposure is a rare complication after intrascleral fixation. It happens partly because the IOL haptic is long and mechanically connected with the optic. It is
Volume 45 Issue 11 November 2019
possible that outward counterforce on the haptics can arise by rubbing the eye. Suture exposure after IOL suturing is also an issue. It is because the sharpness of the end of the 10-0 polypropylene suture. On the other hand, in our case series, the suture was cut very short, the iris exerted no outward force on the suture, and the tip was round by heat. Therefore, continued follow-up will be required for all cases, although we have not noted its exposure on the conjunctiva in any case up to 1 year (Figure 5). The technique to repair a traumatic or surgical wound by pinching the tissue, such as with a surgical stapler, rather than suturing it is used in digestive organ surgeries.4 In ophthalmology, riveting has been attempted for retinal detachment,6 but there has been little success. We speculated whether pinching the tissue would be effective with
TECHNIQUE: IRIDODIALYSIS REPAIR BY DOUBLE-FLANGED SUTURES AS RIVETS
1533
Figure 2. Comparison of the shapes of the iris before and after the surgery. A and B: Preoperatively before mydriasis. C: Preoperatively after mydriasis. A0 , B0 , and C0 : Postoperative photographs of the same eyes, respectively.
a modified polypropylene suture depending on the situation. We named this technique of pinching the tissue using modified 6-0 polypropylene suture as “riveting.” Herein, we
reported on iridodialysis; however, we believe this technique can be applied to other surgeries, such as ciliary body dialysis and IOL fixation.
Figure 3. Schemas of the conventional method (A) and the new technique (B).
Figure 4. The case of wide iridodialysis. A: The conventional method. B: The new technique.
Volume 45 Issue 11 November 2019
1534
TECHNIQUE: IRIDODIALYSIS REPAIR BY DOUBLE-FLANGED SUTURES AS RIVETS
Figure 5. Photographs taken after the surgery. A: There is no exposure on the conjunctiva. B: The flange using the gonio lens can be seen.
REFERENCES WHAT WAS KNOWN The repair of iridodialysis is difficult because of the softness and flexibility of the iris, and because of the narrow surgical space between the cornea and the lens. It is also difficult because the needle has to be moved back and forth. In other fields, a knotless clipping technique is replacing the suturing technique.
WHAT THIS PAPER ADDS Noting that the polypropylene suture can be flanged by heat and used in the process of intrascleral intraocular lens fixation, double-flanged sutures were applied as rivets to repair iridodialysis. This technique can be useful for wide iridodialysis, which must be sutured more than once, because the needle is moved in only one way and it is not necessary to make a loop.
Volume 45 Issue 11 November 2019
1. Okamoto Y, Yamada S, Akimoto M. Suturing repair of subtotal iridodialysis. Int Ophthalmol 2018; 38:395–398 2. Voykov B. Knotless technique for iridodialysis repair. Clin Exp Ophthalmol 2016; 44:135–136 3. Snyder ME, Lindsell LB. Nonappositional repair of iridodialysis. J Cataract Refract Surg 2011; 37:625–628 4. Iavazzo C, Gkegkes ID, Vouloumanou EK, Mamais I, Peppas G, Falagas ME. Sutures versus staples for the management of surgical wounds: a metaanalysis of randomized controlled trials. Am Surg 2011; 77:1206–1221 5. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Opthalmology 2017; 124:1136–1142 6. de Juan E Jr, Hickingbotham D, Machemer R. Retinal tacks. Am J Ophthalmol 1985; 99:272–274
Disclosures: Dr. Akimoto is a consultant to Kowa Co. Ltd. None of the authors has a financial or proprietary interest in any material or method mentioned.