Glued IOL with trifold technique: An iris repair method for large nonappositional defects

Iris repair surgeries have been widely described in the literature.

The major difficulty faced during the surgical learning is the skill of delicately handling sutures with thin iris tissue. With numerous techniques available, the surgeon is left with difficulties when it comes to large nonappositional iris dialysis and iris tears. In such scenarios, we can use a trifold method to appose a large iris defect with a combination of techniques. In this column, we describe the method and its use in brief.

Examining an iris trauma

Preoperatively, in any iris trauma case, initial assessment includes visual acuity, IOP assessment by noncontact method, slit lamp examination, anterior segment OCT and fundus examination. In all cases of trauma, initial examination always focuses on deciding whether an injury is open or closed. When a closed globe injury is confirmed, further examination of the anterior segment for iris, lens and retinal damages is important. In the case of an iris injury, observe the clock hours of iris tear, presence or absence of dialysis, presence or absence of hyphema, multiple or continuous tears, and any avulsion. Clinical pictures with a digital slit lamp can be taken for documentation. Ultrasound B-scan is vital in closed globe injuries. Zonular weakness and lens injury should also be inspected for cataract and phacodonesis or subluxation.

Iris defects

Iris defects can be appositional (when iris suturing is easy to appose without traction) and nonappositional (when suturing is not direct or simple and apposing two torn leaflets of iris is difficult due to large interspace distance). Nonappositional iris defects can be small or large. Because iris trauma is often associated with zonular injury and lens damage, it is better to manage them in the same sitting. Hence, once the preliminary evaluation is performed, the patient is told about the nature of the damage and the need for a procedure. With informed consent, he or she will be taken for iris repair and cataract surgery, as many times there is coexisting zonular damage and cataract formation at presentation.

Trifold technique

In the trifold method, there are basically three steps involved in sequential iris repair. The first two steps are primarily to reduce the distance between the two disinserted iris flaps. This is executed by suturing the iris ends by trocar-assisted iris repair to the sclera. This is performed on either side of the iris defects. The third step is pupil reformation by single-pass four-throw (SFT) pupilloplasty.

Trifold method with glued IOL

We had a case of traumatic lens damage with an iris defect (nonappositional iris defect) (Figure 1a) in a patient who underwent iris repair using the trifold technique along with a glued IOL. The surgery was performed under peribulbar anesthesia in an operating room with aseptic precautions. A trocar anterior chamber maintainer was initially placed for chamber maintenance (Figure 1b). Lensectomy was performed using a conventional phacoemulsification probe from a superior incision. Two partial-thickness lamellar scleral flaps were made diagonally, and 25-gauge sclerotomies were made below the flaps, about 1.2 mm from the limbus. A three-piece IOL was injected through the superior wound, and the haptics were grasped via end-grip forceps through the sclerotomy below the flap by the handshake method and tucked in scleral tunnels. The corneal wound was then secured with 10-0 monofilament nylon sutures.

After positioning the glued IOL, iris defect repair using the trifold method was initiated. We performed the trocar-assisted iris repair procedure initially (Figure 1c), which was a modification of Synder’s hang-back technique for iris repair. A superior scleral tunnel incision was made in the region of expected iris reattachment. A 25-gauge trocar was introduced from the limbus in the direction diagonal to iris insertion (Figures 1c and 1d). In trocar-assisted repair, the trocar has to be placed in the quadrant of the iris defect to be repaired. Once it was placed in position, the trocar needle was withdrawn, and a 10-0 polypropylene suture needle long arm was guided through it, as it engaged the peripheral proximal disinserted iris (Figure 1c). The Prolene needle end was then docked via a 30-gauge needle passed from the sclera at the level of the original insertion of the iris. The suture was passed in the same method for the distal iris, and the knot was tied subsclerally (Figures 1d and 1e). One can see the change in configuration of the iris as the first suture keeps the contour in place (Figure 1f).

The same technique was repeated in the other nonappositional iris end (Figures 2a and 2b). After completing the trocar-assisted iris repair on either end, the iris defect was apparently made small (Figures 2b and 2c). One can clinically see the distance between the iris leaflets reduced as the initial two steps were done. Finally, the pupil configuration was performed using the conventional SFT technique (Figure 2d). The polypropylene single-arm suture was passed from the proximal iris through a paracentesis incision and was subsequently docked through a 26-gauge needle passed through the distal iris via an opposite stab incision. The suture end was withdrawn along with the suture needle end. A Sinskey hook was then introduced inside the anterior chamber to form a loop that was pulled through the opposite paracentesis. The loops were placed onto the conjunctiva, the suture end was then passed four times into the loop, and the two ends were pulled to approximate the knot, which subsequently slid on the iris in the anterior chamber. The suture ends were cut within the anterior chamber by micro-scissors away from the knot. The postoperative period was uneventful, and a steroid-antibiotic combination was used for 1 month. Visual acuity improved in the patient, who was comfortable without glare or photosensitivity.

Conclusion

Iris defects are rare complications of trauma and surgery. However, managing them requires timely intervention because when untreated, they are known to cause visual quality disturbances such as glare and photosensitivity. Rarely, some patients also complain of cosmetic effects. Even though varied types of procedures are available, choosing the right method is vital. The trifold technique is a novel addition to the list of repair procedures and can be highly useful in large nonappositional iris defects.

• References:
• Agarwal A, et al. J Cataract Refract Surg. 2008;doi:10.1016/j.jcrs.2008.04.040.
• Agarwal A, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.01.019.
• Narang P, et al. Eur J Ophthalmol. 2018;doi:10.1177/1120672117747038.
• Narang P, et al. Eur J Ophthalmol. 2021;doi:10.1177/1120672120948747.
• Snyder ME, et al. J Cataract Refract Surg. 2011;doi:10.1016/j.jcrs.2011.02.001.

• For more information:
• Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, is the author of several books, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at aehl19c@gmail.com; website: www.dragarwal.com.

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