- Email: [email protected]
Single-point pivot for combined repair of concurrent iridodialysis and cyclodialysis
1306
TECHNIQUE
Single-point pivot for combined repair of concurrent iridodialysis and cyclodialysis Shikha Gupta, MD, Harathy Selvan, MD, Azmira Kishan, MD, Navarosh Jayaraman, MBBS, Viney Gupta, MD
Iridodialysis and cyclodialysis can occur simultaneously in patients with blunt trauma to the eye, and both might necessitate surgical correction when symptoms emerge. Numerous techniques are used to repair each dialysis individually; thus, the patient will have to return to the operating room for each additional surgery. To our knowledge, the literature lacks techniques to manage both conditions simultaneously. We developed a new approach in which both dialyses can be repaired using a single suture, pivoting both at the same point. The suture that passes through the
S
udden anteroposterior globe compression in cases of blunt trauma is characterized by momentary equatorial expansion, causing tissues anterior to the equator to tear.1 Although all seven rings of trauma rarely coexist,2 it is not uncommon to find iridodialysis and cyclodialysis occurring together because the tissues are bound one over the other and insert together. Large iridodialysis and cyclodialysis must be surgically treated,3,4 and this often requires two separate operating room visits. Numerous techniques have been described to correct each condition individually. We describe the use of a combined approach for simultaneous restoration of both tissues through a single suture loop. To our knowledge, this is the first report of such a technique. We used this technique in a male patient whose right eye was injured by a firecracker. Eight months after trauma, the patient reported a gradual-onset, progressive decrease in vision in the right eye. On examination, the corrected distance visual acuity (CDVA) was 6/18 in the right eye and 6/6 the left eye. The intraocular pressure (IOP) was 6 mm Hg and 14 mm Hg, respectively. Slitlamp examination of the right eye showed sphincter tears, a D-shaped pupil with a superior 2 to 3 clock hour iridodialysis, posterior synechiae, and a posttraumatic cataract (Figure 1, A). Gentle indirect Goldmann gonioscopy showed a significantly more extensive iridodialysis (9 to 1 o’clock position) and a large cyclodialysis cleft (10 to 1 o’clock position),
eyelet of the capsular tension ring placed in the sulcus (for internal cyclopexy) is further passed through the detached iris root and retracted via the ciliary cleft to be tied over the scleral bed, facilitating closure of both dialyses at the same time. This is an effective approach for the repair of concurrent iridodialysis and cyclodialysis. J Cataract Refract Surg 2018; 44:1306–1309 Q 2018 ASCRS and ESCRS Online Video
explaining the hypotony (Figure 2, A). Ultrasound biomicroscopy confirmed the presence of cyclodialysis cleft (Figure 3, A). On fundus examination, a blurred disc margin and macular folds were visible, consistent with hypotonic maculopathy. Hence, the diagnosis for the right eye was posttraumatic cataract with concurrent superior iridodialysis and cyclodialysis with hypotonic maculopathy. The left eye was within normal limits. SURGICAL TECHNIQUE Under peribulbar anesthesia, an intraoperative examination with Swan-Jacob direct gonioprism was performed to determine the maximum extent of the cyclodialysis, which was clearly visible because of the coexisting iridodialysis. Phacoaspiration was then performed uneventfully. Next, a localized superotemporal peritomy was performed and a 4.0 mm 3.0 mm partial-thickness scleral flap coinciding with the center of the cleft was created. A foldable singlepiece acrylic intraocular lens (IOL) was implanted in the capsular bag, and the anterior chamber was formed with a cohesive ophthalmic viscosurgical device. One arm of a double-armed straight needle 9-0 polypropylene (Prolene) suture was passed through eyelet of a modified capsular tension ring (CTR) (Morcher 1L/Cionni single eyelet ring 10/12) and looped outside the globe under microscopic view. Then, a bent 26-gauge needle was passed through the partial-thickness scleral bed 3.5 mm from the
Submitted: March 27, 2018 | Final revision submitted: July 28, 2018 | Accepted: August 7, 2018 From the Glaucoma Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Ramchandra B. Pokale provided the drawings for Figure 5. Corresponding author: Shikha Gupta, MD, Glaucoma Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India. Email: [email protected]. Q 2018 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2018.08.004
TECHNIQUE: SINGLE-POINT PIVOT TO SIMULTANEOUSLY REPAIR IRIDODIALYSIS AND CYCLODIALYSIS
1307
Figure 1. A: Preoperative slitlamp biomicroscopy shows a large superior iridodialysis and cataract. B: Postoperative photograph (4 weeks) shows a normotensive eye and correction of the iridodialysis.
limbus. The needle entered the posterior chamber through the ciliary body cleft, after which it was brought in front of the torn iris tissue in a bevel-up position. This was performed under direct gonioscopic visualization using a Swan-Jacob gonioprism (Figure 4, A) to ensure passage across the maximum height of the cleft. The polypropylene needle that had passed through the eyelet was bent for easier maneuverability. One of the needles of 9-0 polypropelene sutures was inserted through an opposite 2.2 mm clear corneal incision (CCI) (inferior) and directed into the opposite sulcus to slide behind the detached iris. Then, the needle was passed through the peripheral-most part of the detached iris and was docked into the 26-gauge needle, thus untwirling the rolled-over iris root (Figure 4, B). This 26 gauge-polypropylene needle assembly was gently withdrawn through the scleral bed. The process was repeated with the other polypropylene needle. Next, the CTR was rotated into the sulcus with a McPherson forceps through the inferior 2.2 mm incision (Figure 4, C). The withdrawal of the needle complex and titrated tightening of the polypropylene sutures caused the ring to lie abutting the ciliary body, correcting both the dialyses (Figure 4, D); this was confirmed on gonioscopy. The surgery was concluded by suturing the scleral flap, conjunctiva, and forming the anterior chamber. The surgical steps are shown in Video 1 (available at http://jcrsjournal.org) as well as in Figure 5. RESULTS By 1 day postoperatively, the CDVA in the right eye had improved to 6/9, the IOP was 16 mm Hg, and slitlamp examination showed an optimally apposed iris. At the 1-week follow-up visit, the vision was 6/6, the IOP 16 mm Hg, and the fundus showed resolution of hypotonic maculopathy with distinct disc borders and a sharp foveal reflex. At the 4-week follow-up, indirect gonioscopy confirmed cleft
closure and because the iris was anchored onto the face of the ciliary body, the ciliary processes posterior to the anchor suture could still be visualized (Figure 2, B). The pupil was superiorly updrawn with focal iris atrophy at the pupillary border, probably as a consequence of posttraumatic sphincter tears. However, the patient did not report visual distortion secondary to focal iris dilation. At visits during the 6-month follow-up, the IOP remained between 15 mm Hg and 20 mm Hg. DISCUSSION A cyclodialysis requires repair when associated with persistent hypotony, as does a very large iridodialysis that occludes the central visual axis or causes symptoms. Direct external cyclopexy is used to treat cyclodialysis clefts that are resistant to conservative management.5,6 However, successful closure of large clefts using endotamponade techniques such as a CTR in the sulcus has also been reported.5,7 The latter technique is easier and safer than external cyclopexy because it requires minimal manipulation; in addition, it effectively treats the low-lying clefts that are not visible because of their circumferential cerclage effect. Repairing both the dialyses individually using different sutures at the same sitting is more time consuming and requires repeated tissue handling. Hence, surgeons usually attempt closure of such twin dialyses in two surgical sittings to minimize inflammation. Furthermore, the presence of two nonabsorbable sutures, one to repair iridodialysis and one to repair cyclodialysis, potentially increases the risk for long-term infection and suture-related complications. Hence, we propose a technique in which the detached iris and ciliary body are hinged together at a common point using the same suture, repairing both the dialyses simultaneously. This technique increases the safety and decreases the time of the surgery and is more economical. Figure 2. A: Preoperative indirect gonioscopy of the superior angle shows a large iridodialysis through which the ciliary processes and the cyclodialysis cleft are visible (black arrow). B: Postoperative gonioscopy shows a closed cyclodialysis cleft with iris root hinged onto the ciliary body through a single suture knot, exposing the ciliary processes posterior to the suture.
Volume 44 Issue 11 November 2018
1308
TECHNIQUE: SINGLE-POINT PIVOT TO SIMULTANEOUSLY REPAIR IRIDODIALYSIS AND CYCLODIALYSIS
Figure 3. Ultrasound biomicroscopic images (50 MHz, 85 dB gain). A: Preoperative cyclodialysis cleft (white arrow). B: Cleft closure postoperatively. Note the posterior chamber intraocular lens, eyelet of the capsular tension ring (white arrow with open head), and suture tract across the ciliary body (white arrow with closed head).
Direct gonioscopy during such procedures, which was facilitated by the coexisting iridodialysis, provided accurate details of the extent and height of the cleft. This enabled good and relatively easy alignment of the CTR. In addition, the 26-gauge needle is passed under monitor of a direct goniolens, allowing visualization of the full-thickness passage through the cleft and ciliary body in real time and increasing the preciseness of the maneuver. This was followed by iris repair in continuation. Diverse techniques to repair iridodialysis have been proposed.8–13 One is the stroke-and-dock technique, in which the 26-gauge needle inserted through the scleral bed is stroked under the iris at its most peripheral part to unfold it and the polypropylene needle entering from the opposite side is docked into the 26-gauge needle from over the iris and then pulled through the scleral bed.13 The technique we describe here does the opposite. The 26-gauge needle is passed over the iris surface, and the polypropylene needle is inserted from behind the iris so the suture passes from posteriorly to anteriorly. Thus, we call this the reverse stroke-and-dock method. The suture through iris can be passed either from above or
below the iris plane because it is tied over the scleral bed in a hanging-loop fashion. The reverse stroke is technically demanding, however. It is easy to pierce the iris with the bent 26-gauge needle from the anterior when the needle is advanced beneath the iris toward the opposite CCI to enable easier peripheral docking of the polypropylene suture. The only postoperative complication was a distorted updrawn pupil that was likely caused by inappropriate pull by the suture and posttraumatic iris atrophy. In future, this complication can be mitigated by completely unfolding the iris tissue, passing the suture through the detached iris base as peripherally as possible, and appropriately titrating the suture knot before the final tie. Over the long-term, no other complications, such as photophobia, ocular pain, or iridocyclitis, occurred. A single polypropylene suture was thus passed through the iris and pulled through the ciliary body, pivoting both on a single point on the sclera, providing anatomic restoration in a physiological manner. This simultaneous repair might reduce costs, intraoperative time, surgical trauma, and long-term suture related side effects.
Figure 4. A: Insertion of 26-gauge needle through the partial-thickness scleral bed under direct gonioscopic visualization to ensure passage of the needle through the entire cleft and the ciliary body. B: Docking of the straight 9-0 polypropylene needle into the 26-gauge needle from behind the iris by reverse stroke-anddock technique. C: Sliding of single-eyelet capsular tension ring with a McPherson forceps into ciliary sulcus. D: Optimum correction of both dialyses after titrating and tying the suture over the scleral bed.
Volume 44 Issue 11 November 2018
TECHNIQUE: SINGLE-POINT PIVOT TO SIMULTANEOUSLY REPAIR IRIDODIALYSIS AND CYCLODIALYSIS
1309
Figure 5. Steps of surgical technique. A: A bent 26-gauge needle is passed through the partial-thickness scleral bed, cyclodialysis cleft, and the ciliary body. A straight-needle polypropylene suture is inserted from an opposite clear corneal incision and docked into the 26-gauge needle, passing through the peripheral edge of the torn iris by reverse stock-and-dock technique. B: Other end of the polypropylene suture that was passed through the eyelet of the CTR was docked in a similar fashion. The CTR is rotated and placed in the sulcus with its eyelet coinciding with the maximum cleft height. C: The ends of the polypropylene suture are titrated and tied on the surface of the scleral bed, pivoting the detached iris and ciliary body at the same point by a single suture (CTR Z capsular tension ring).
WHAT WAS KNOWN Previously reported surgical techniques attempt to repair iridodialysis and cyclodialysis as two separate procedures rather than simultaneously in one operation. These techniques can require repeated tissue handling and additional operating room visits and might pose higher risk for long-term suture-related complications.
WHAT THIS PAPER ADDS The single-point pivot technique hinges the detached iris and ciliary body together at a common point using the same suture. This technique might reduce the risk for long-term suturerelated complications and provides an easy, effective, safe, economical, and faster approach for the repair of concurrent iridodialysis and cyclodialysis.
REFERENCES 1. Campbell DG. Traumatic glaucoma. In: Shingleton BJ. Hersh PS, Kenyon KR, eds, Eye Trauma. St. Louis, MO, Mosby Year Book, 1991; 117–125 2. Kaushik S, Sukhija J, Pandav SS, Gupta A. Blunt ocular trauma in one eye: a photo documentation. Ann Ophthalmol 2006; 38:249–252 3. Barlow A, Weiner HL. Traumatic iridodialysis; its surgical correction. Arch Ophthalmol 1945; 34:292–294 lez-Martín-Moro J, Contreras-Martín I, Mun ~oz-Negrete FJ, Go mez4. Gonza Sanz F, Zarallo-Gallardo J. Cyclodialysis: an update. Int Ophthalmol 2017; 37:441–457 5. Ioannidis AS, Barton K. Cyclodialysis cleft: causes and repair. Curr Opin Ophthalmol 2010; 21:150–154
€chle M, Naumann GOH. Direct cyclopexy for traumatic cyclodialysis with 6. Ku persisting hypotony; report in 29 consecutive patients. Ophthalmology 1995; 102:322–333 7. Gupta S, Sagar P, Gogia V, Khokhar S, Dada T. Dual endotemponade for extensive long-standing cyclodialysis using sulcus-fixated Cionni ring and PCIOL. J Glaucoma 2016; 25:e284–e287 8. Bardak Y, Ozerturk Y, Durmus M, Mensiz E, Aytuluner E. Closed chamber iridodialysis repair using a needle with a distal hole. J Cataract Refract Surg 2000; 26:173–176 9. Yousif MO. Single suture customized loop for large iridodialysis repair. Clin Ophthalmol 2016; 10:1883–1890. Available at: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5047737/pdf/opth-10-1883. pdf. Accessed August 9, 2018 10. Snyder ME, Lindsell LB. Nonappositional repair of iridodialysis. J Cataract Refract Surg 2011; 37:625–628 11. Boxer Wachler BS, Krueger RR. Double-armed McCannel suture for repair of traumatic iridodialysis. Am J Ophthalmol 1996; 122:109–110 12. Pandav SS, Gupta PC, Singh RR, Das K, Kaushik S, Raj S, Ram J. Cobbler’s technique for Iridodialysis repair. Middle East Afr J Ophthalmol 2016; 23:142–144. Available at: https://www.ncbi.nlm.nih.gov/pmc /articles/PMC4759894/?reportZprintable. Accessed August 9, 2018 13. Khokhar S, Gupta S, Kumar G. Iridodialysis repair: stroke and dock technique. Int Ophthalmol 2014; 34:331–335
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned. First author: Shikha Gupta, MD Glaucoma Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Volume 44 Issue 11 November 2018
TECHNIQUE
Single-point pivot for combined repair of concurrent iridodialysis and cyclodialysis Shikha Gupta, MD, Harathy Selvan, MD, Azmira Kishan, MD, Navarosh Jayaraman, MBBS, Viney Gupta, MD
Iridodialysis and cyclodialysis can occur simultaneously in patients with blunt trauma to the eye, and both might necessitate surgical correction when symptoms emerge. Numerous techniques are used to repair each dialysis individually; thus, the patient will have to return to the operating room for each additional surgery. To our knowledge, the literature lacks techniques to manage both conditions simultaneously. We developed a new approach in which both dialyses can be repaired using a single suture, pivoting both at the same point. The suture that passes through the
S
udden anteroposterior globe compression in cases of blunt trauma is characterized by momentary equatorial expansion, causing tissues anterior to the equator to tear.1 Although all seven rings of trauma rarely coexist,2 it is not uncommon to find iridodialysis and cyclodialysis occurring together because the tissues are bound one over the other and insert together. Large iridodialysis and cyclodialysis must be surgically treated,3,4 and this often requires two separate operating room visits. Numerous techniques have been described to correct each condition individually. We describe the use of a combined approach for simultaneous restoration of both tissues through a single suture loop. To our knowledge, this is the first report of such a technique. We used this technique in a male patient whose right eye was injured by a firecracker. Eight months after trauma, the patient reported a gradual-onset, progressive decrease in vision in the right eye. On examination, the corrected distance visual acuity (CDVA) was 6/18 in the right eye and 6/6 the left eye. The intraocular pressure (IOP) was 6 mm Hg and 14 mm Hg, respectively. Slitlamp examination of the right eye showed sphincter tears, a D-shaped pupil with a superior 2 to 3 clock hour iridodialysis, posterior synechiae, and a posttraumatic cataract (Figure 1, A). Gentle indirect Goldmann gonioscopy showed a significantly more extensive iridodialysis (9 to 1 o’clock position) and a large cyclodialysis cleft (10 to 1 o’clock position),
eyelet of the capsular tension ring placed in the sulcus (for internal cyclopexy) is further passed through the detached iris root and retracted via the ciliary cleft to be tied over the scleral bed, facilitating closure of both dialyses at the same time. This is an effective approach for the repair of concurrent iridodialysis and cyclodialysis. J Cataract Refract Surg 2018; 44:1306–1309 Q 2018 ASCRS and ESCRS Online Video
explaining the hypotony (Figure 2, A). Ultrasound biomicroscopy confirmed the presence of cyclodialysis cleft (Figure 3, A). On fundus examination, a blurred disc margin and macular folds were visible, consistent with hypotonic maculopathy. Hence, the diagnosis for the right eye was posttraumatic cataract with concurrent superior iridodialysis and cyclodialysis with hypotonic maculopathy. The left eye was within normal limits. SURGICAL TECHNIQUE Under peribulbar anesthesia, an intraoperative examination with Swan-Jacob direct gonioprism was performed to determine the maximum extent of the cyclodialysis, which was clearly visible because of the coexisting iridodialysis. Phacoaspiration was then performed uneventfully. Next, a localized superotemporal peritomy was performed and a 4.0 mm 3.0 mm partial-thickness scleral flap coinciding with the center of the cleft was created. A foldable singlepiece acrylic intraocular lens (IOL) was implanted in the capsular bag, and the anterior chamber was formed with a cohesive ophthalmic viscosurgical device. One arm of a double-armed straight needle 9-0 polypropylene (Prolene) suture was passed through eyelet of a modified capsular tension ring (CTR) (Morcher 1L/Cionni single eyelet ring 10/12) and looped outside the globe under microscopic view. Then, a bent 26-gauge needle was passed through the partial-thickness scleral bed 3.5 mm from the
Submitted: March 27, 2018 | Final revision submitted: July 28, 2018 | Accepted: August 7, 2018 From the Glaucoma Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Ramchandra B. Pokale provided the drawings for Figure 5. Corresponding author: Shikha Gupta, MD, Glaucoma Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India. Email: [email protected]. Q 2018 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2018.08.004
TECHNIQUE: SINGLE-POINT PIVOT TO SIMULTANEOUSLY REPAIR IRIDODIALYSIS AND CYCLODIALYSIS
1307
Figure 1. A: Preoperative slitlamp biomicroscopy shows a large superior iridodialysis and cataract. B: Postoperative photograph (4 weeks) shows a normotensive eye and correction of the iridodialysis.
limbus. The needle entered the posterior chamber through the ciliary body cleft, after which it was brought in front of the torn iris tissue in a bevel-up position. This was performed under direct gonioscopic visualization using a Swan-Jacob gonioprism (Figure 4, A) to ensure passage across the maximum height of the cleft. The polypropylene needle that had passed through the eyelet was bent for easier maneuverability. One of the needles of 9-0 polypropelene sutures was inserted through an opposite 2.2 mm clear corneal incision (CCI) (inferior) and directed into the opposite sulcus to slide behind the detached iris. Then, the needle was passed through the peripheral-most part of the detached iris and was docked into the 26-gauge needle, thus untwirling the rolled-over iris root (Figure 4, B). This 26 gauge-polypropylene needle assembly was gently withdrawn through the scleral bed. The process was repeated with the other polypropylene needle. Next, the CTR was rotated into the sulcus with a McPherson forceps through the inferior 2.2 mm incision (Figure 4, C). The withdrawal of the needle complex and titrated tightening of the polypropylene sutures caused the ring to lie abutting the ciliary body, correcting both the dialyses (Figure 4, D); this was confirmed on gonioscopy. The surgery was concluded by suturing the scleral flap, conjunctiva, and forming the anterior chamber. The surgical steps are shown in Video 1 (available at http://jcrsjournal.org) as well as in Figure 5. RESULTS By 1 day postoperatively, the CDVA in the right eye had improved to 6/9, the IOP was 16 mm Hg, and slitlamp examination showed an optimally apposed iris. At the 1-week follow-up visit, the vision was 6/6, the IOP 16 mm Hg, and the fundus showed resolution of hypotonic maculopathy with distinct disc borders and a sharp foveal reflex. At the 4-week follow-up, indirect gonioscopy confirmed cleft
closure and because the iris was anchored onto the face of the ciliary body, the ciliary processes posterior to the anchor suture could still be visualized (Figure 2, B). The pupil was superiorly updrawn with focal iris atrophy at the pupillary border, probably as a consequence of posttraumatic sphincter tears. However, the patient did not report visual distortion secondary to focal iris dilation. At visits during the 6-month follow-up, the IOP remained between 15 mm Hg and 20 mm Hg. DISCUSSION A cyclodialysis requires repair when associated with persistent hypotony, as does a very large iridodialysis that occludes the central visual axis or causes symptoms. Direct external cyclopexy is used to treat cyclodialysis clefts that are resistant to conservative management.5,6 However, successful closure of large clefts using endotamponade techniques such as a CTR in the sulcus has also been reported.5,7 The latter technique is easier and safer than external cyclopexy because it requires minimal manipulation; in addition, it effectively treats the low-lying clefts that are not visible because of their circumferential cerclage effect. Repairing both the dialyses individually using different sutures at the same sitting is more time consuming and requires repeated tissue handling. Hence, surgeons usually attempt closure of such twin dialyses in two surgical sittings to minimize inflammation. Furthermore, the presence of two nonabsorbable sutures, one to repair iridodialysis and one to repair cyclodialysis, potentially increases the risk for long-term infection and suture-related complications. Hence, we propose a technique in which the detached iris and ciliary body are hinged together at a common point using the same suture, repairing both the dialyses simultaneously. This technique increases the safety and decreases the time of the surgery and is more economical. Figure 2. A: Preoperative indirect gonioscopy of the superior angle shows a large iridodialysis through which the ciliary processes and the cyclodialysis cleft are visible (black arrow). B: Postoperative gonioscopy shows a closed cyclodialysis cleft with iris root hinged onto the ciliary body through a single suture knot, exposing the ciliary processes posterior to the suture.
Volume 44 Issue 11 November 2018
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TECHNIQUE: SINGLE-POINT PIVOT TO SIMULTANEOUSLY REPAIR IRIDODIALYSIS AND CYCLODIALYSIS
Figure 3. Ultrasound biomicroscopic images (50 MHz, 85 dB gain). A: Preoperative cyclodialysis cleft (white arrow). B: Cleft closure postoperatively. Note the posterior chamber intraocular lens, eyelet of the capsular tension ring (white arrow with open head), and suture tract across the ciliary body (white arrow with closed head).
Direct gonioscopy during such procedures, which was facilitated by the coexisting iridodialysis, provided accurate details of the extent and height of the cleft. This enabled good and relatively easy alignment of the CTR. In addition, the 26-gauge needle is passed under monitor of a direct goniolens, allowing visualization of the full-thickness passage through the cleft and ciliary body in real time and increasing the preciseness of the maneuver. This was followed by iris repair in continuation. Diverse techniques to repair iridodialysis have been proposed.8–13 One is the stroke-and-dock technique, in which the 26-gauge needle inserted through the scleral bed is stroked under the iris at its most peripheral part to unfold it and the polypropylene needle entering from the opposite side is docked into the 26-gauge needle from over the iris and then pulled through the scleral bed.13 The technique we describe here does the opposite. The 26-gauge needle is passed over the iris surface, and the polypropylene needle is inserted from behind the iris so the suture passes from posteriorly to anteriorly. Thus, we call this the reverse stroke-and-dock method. The suture through iris can be passed either from above or
below the iris plane because it is tied over the scleral bed in a hanging-loop fashion. The reverse stroke is technically demanding, however. It is easy to pierce the iris with the bent 26-gauge needle from the anterior when the needle is advanced beneath the iris toward the opposite CCI to enable easier peripheral docking of the polypropylene suture. The only postoperative complication was a distorted updrawn pupil that was likely caused by inappropriate pull by the suture and posttraumatic iris atrophy. In future, this complication can be mitigated by completely unfolding the iris tissue, passing the suture through the detached iris base as peripherally as possible, and appropriately titrating the suture knot before the final tie. Over the long-term, no other complications, such as photophobia, ocular pain, or iridocyclitis, occurred. A single polypropylene suture was thus passed through the iris and pulled through the ciliary body, pivoting both on a single point on the sclera, providing anatomic restoration in a physiological manner. This simultaneous repair might reduce costs, intraoperative time, surgical trauma, and long-term suture related side effects.
Figure 4. A: Insertion of 26-gauge needle through the partial-thickness scleral bed under direct gonioscopic visualization to ensure passage of the needle through the entire cleft and the ciliary body. B: Docking of the straight 9-0 polypropylene needle into the 26-gauge needle from behind the iris by reverse stroke-anddock technique. C: Sliding of single-eyelet capsular tension ring with a McPherson forceps into ciliary sulcus. D: Optimum correction of both dialyses after titrating and tying the suture over the scleral bed.
Volume 44 Issue 11 November 2018
TECHNIQUE: SINGLE-POINT PIVOT TO SIMULTANEOUSLY REPAIR IRIDODIALYSIS AND CYCLODIALYSIS
1309
Figure 5. Steps of surgical technique. A: A bent 26-gauge needle is passed through the partial-thickness scleral bed, cyclodialysis cleft, and the ciliary body. A straight-needle polypropylene suture is inserted from an opposite clear corneal incision and docked into the 26-gauge needle, passing through the peripheral edge of the torn iris by reverse stock-and-dock technique. B: Other end of the polypropylene suture that was passed through the eyelet of the CTR was docked in a similar fashion. The CTR is rotated and placed in the sulcus with its eyelet coinciding with the maximum cleft height. C: The ends of the polypropylene suture are titrated and tied on the surface of the scleral bed, pivoting the detached iris and ciliary body at the same point by a single suture (CTR Z capsular tension ring).
WHAT WAS KNOWN Previously reported surgical techniques attempt to repair iridodialysis and cyclodialysis as two separate procedures rather than simultaneously in one operation. These techniques can require repeated tissue handling and additional operating room visits and might pose higher risk for long-term suture-related complications.
WHAT THIS PAPER ADDS The single-point pivot technique hinges the detached iris and ciliary body together at a common point using the same suture. This technique might reduce the risk for long-term suturerelated complications and provides an easy, effective, safe, economical, and faster approach for the repair of concurrent iridodialysis and cyclodialysis.
REFERENCES 1. Campbell DG. Traumatic glaucoma. In: Shingleton BJ. Hersh PS, Kenyon KR, eds, Eye Trauma. St. Louis, MO, Mosby Year Book, 1991; 117–125 2. Kaushik S, Sukhija J, Pandav SS, Gupta A. Blunt ocular trauma in one eye: a photo documentation. Ann Ophthalmol 2006; 38:249–252 3. Barlow A, Weiner HL. Traumatic iridodialysis; its surgical correction. Arch Ophthalmol 1945; 34:292–294 lez-Martín-Moro J, Contreras-Martín I, Mun ~oz-Negrete FJ, Go mez4. Gonza Sanz F, Zarallo-Gallardo J. Cyclodialysis: an update. Int Ophthalmol 2017; 37:441–457 5. Ioannidis AS, Barton K. Cyclodialysis cleft: causes and repair. Curr Opin Ophthalmol 2010; 21:150–154
€chle M, Naumann GOH. Direct cyclopexy for traumatic cyclodialysis with 6. Ku persisting hypotony; report in 29 consecutive patients. Ophthalmology 1995; 102:322–333 7. Gupta S, Sagar P, Gogia V, Khokhar S, Dada T. Dual endotemponade for extensive long-standing cyclodialysis using sulcus-fixated Cionni ring and PCIOL. J Glaucoma 2016; 25:e284–e287 8. Bardak Y, Ozerturk Y, Durmus M, Mensiz E, Aytuluner E. Closed chamber iridodialysis repair using a needle with a distal hole. J Cataract Refract Surg 2000; 26:173–176 9. Yousif MO. Single suture customized loop for large iridodialysis repair. Clin Ophthalmol 2016; 10:1883–1890. Available at: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5047737/pdf/opth-10-1883. pdf. Accessed August 9, 2018 10. Snyder ME, Lindsell LB. Nonappositional repair of iridodialysis. J Cataract Refract Surg 2011; 37:625–628 11. Boxer Wachler BS, Krueger RR. Double-armed McCannel suture for repair of traumatic iridodialysis. Am J Ophthalmol 1996; 122:109–110 12. Pandav SS, Gupta PC, Singh RR, Das K, Kaushik S, Raj S, Ram J. Cobbler’s technique for Iridodialysis repair. Middle East Afr J Ophthalmol 2016; 23:142–144. Available at: https://www.ncbi.nlm.nih.gov/pmc /articles/PMC4759894/?reportZprintable. Accessed August 9, 2018 13. Khokhar S, Gupta S, Kumar G. Iridodialysis repair: stroke and dock technique. Int Ophthalmol 2014; 34:331–335
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned. First author: Shikha Gupta, MD Glaucoma Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Volume 44 Issue 11 November 2018