Ординатура / Офтальмология / Учебные материалы / Clinical Diagnosis and Management of ocular trauma

96

Clinical Diagnosis and Management of Ocular Trauma

2 POINT FIXATION

ANTERIORAPPROACH

In this technique, the IOL is fixed to the sclera at 2

In the anterior approach, the SFIOL is inserted after

points with 2 10-0 prolene sutures. This is a faster

doing only anterior and core vitrectomy from the

technique and less cumbersome. Hence, it is easier

anterior approach with making the par plana

to perform and good for beginners. However, the

sclerotomies. The advantage of this approach is that

stability of the IOL is lesser as compared to 4 point

it is simpler and easier to perform. The technique is

fixation and the chances of decentration or tilts are

also faster. However, the chances of postoperative

higher.

complications are higher as the removal of vitreous

4 POINT FIXATION

is incomplete and this can be a constant source of

irritation resulting in chronic cystoid macular edema,

In this technique, the IOL is fixed to the sclera at 4

secondary glaucoma or uveitis.

points with 10-0 prolene sutures. However, it requires

more skill and is more time consuming. The sutures

POSTERIORAPPROACH

can get entangled and a mix-up of sutures can cause

In this approach, conventional 3 port pars plana

improper fixation of the IOL. Hence this procedure

vitrectomy is performed completely with an induction

can become cumbersome and difficult to perform.

of posterior vitreous detachment. Limited base excision

AB-INTERNO TECHNIQUE

is also performed in the area where the SFIOL will

be placed. The SFIOL is then inserted either with the

This is a blind technique wherein after making 3 mm

ab-externo or the ab-interno technique by 2 point or

× 3 mm scleral flaps at the limbus, the 10-0 prolene

4 point fixation.

needle is passed through the eyelet of the haptic and

We preferably perform ab-externo 4 point fixation

then the needle is passed through the AC and brought

of SFIOL by the posterior approach in traumatized

out about 1 mm from the limbus under the scleral

eyes and it will be described in detail.

flaps. This technique requires lot of skill and experience

• After doing routine surgical asepsis, the eye to be

as while passing the needle underneath the iris, it can

operated is painted and draped.

damage the iris itself or the ciliary body or in some

•

270 degree conjunctival peritomy is performed.

cases if the needle goes more posteriorly it can cause

•

2 partial thickness square shaped limbal based

breaks in the retina and can cause a retinal detachment.

scleral flaps of 3 × 3 mm are made at 3 and

Also the most important factor which makes it a non-

9 O’ clock.

preferred technique by many is that the placement

• A self sealing trilaminar 7 mm scleral tunnel is made

of IOL is more posterior with this technique rather

at 12 O’ clock.

than in the ciliary sulcus as has been found in many

• 3 sclerotomies are made at 3 mm from the limbus.

studies. Hence, this technique although fast may not

•

If a cataract is present, then lensectomy is done

be suitable for beginners and who are inexperienced.

with a vitrectomy cutter. In cases where the cataract

AB-EXTERNO TECHNIQUE

is dense, it is either delivered out through the tunnel

or by phacoemulsification.

This technique is easier to perform and requires little

• Complete par plana vitrectomy is done. In cases

experience and the learning curve is faster. Also, the

where the posterior vitreous is not detached, PVD

procedure is done under direct view and hence more

is induced with either by suction or by an

accurate as to the placement of the IOL perfectly in

intraocular forceps. In traumatized eyes this step

the sulcus. In this procedure after making scleral flaps

is very important as the chances of a cystoid

or grooves, a 27G needle is passed 1mm from the

macular edema are very high. Also if the PVD gets

limbus into the eye behind the iris and held in place

induced in the postoperative period it can lead to

in the pupillary axis. From the opposite side, a

retinal break formation in the already compromised

10-0 prolene suture with a straight needle is passed

eye and cause retinal detachment.

into the eye and passed into the bore of the 27G needle

• Then limited base excision is done in the region

under observation and the 27G needle is pulled out

where the SFIOL haptics will be placed; in this case

bringing with it the needle. A superior 7 mm wound

is then created and the loops brought out, cut and tied

at 3 O’clock and 9 O’ clock position. This has

to the eyelets of the haptics of an SFIOL and the IOL

2 advantages. It prevents the constant irritation of

is then inserted in sulcus and the sutures pulled out and

the vitreous by the haptics on movement of the

fixed to the sclera in the bed. The flaps are then sutured

eye and also prevents traction on the vitreous by

back with 7-0 vicryl covering the prolene knot.

the haptics preventing retinal breaks.

Scleral Fixated IOL in Trauma

97

• A detailed fundus examination is then carried out

This can induce fresh breaks in some instances and

with indirect ophthalmoscope with scleral inden-

can cause retinal detachment. Also, the trauma can

tation.

cause macular involvement by way of a traumatic

• Any breaks in the retina or dialysis or suspicious

chronic cystoid macular edema or an epiretinal

areas are treated with cryopexy.

membrane formation or, in some cases, full-thickness

• A double armed 10-0 prolene suture with straight

macular holes. These can also be managed during the

needle is used for the procedure. The suture is cut

IOL implantation itself by combining it with total

in the center.

vitrectomy with internal limiting membrane peeling.

the iris and help in place in the pupillary area. The

Complications of SFIOL

needle of the 10-0 prolene suture is then passed

CYSTOID MACULAR EDEMA

from the opposite side and passed into the bore

of the 27G needle and the needle is withdrawn

It is the most common complication seen after ant IOL

pulling the suture along with it. The procedure is

implantation. The incidence increases whenever it is

repeated on the superior end of the grooves. So,

associated with complications. In the absence of the

now there are 2 10-0 prolene sutures passing across

posterior capsule this more common due to the antero-

the anterior chamber behind the iris with the ends

posterior vitreous traction on the macula. In

of the sutures on the outside.

traumatised eyes, the trauma itself may cause CME,

• The loops of the sutures are then brought out from

more often chronic and non-responding. This can be

the scleral tunnel and cut in the center and the

reduced with good vitrectomy releasing all traction on

ends secured.

the macula and preferably with an induction of PVD.

• The sutures on the left side are then to the eyelet

GLAUCOMA

of the haptic of an SFIOL. The procedure is

repeated on the other side.

This is also fairly common with SFIOL. This can be

•

The IOL is then inserted in the sulcus and the

due to incomplete vitrectomy or due to viscoelastic

sutures are pulled out on either side taking care

device induced. It can also be secondary to entangled

that the IOL does not flip.

vitreous in the vitreous which can cause uveitic

•

The left side sutures are then tied to each other

glaucoma. Rarely, the SFIOL can cause a pupillary

and the procedure is repeated on the other side.

block and lead to rise in IOP. In same cases glaucoma

• The ends of the knots are left long, about 1 mm,

can be unrelated to the SFIOL itself and can be due

and are covered by the scleral flaps and the flaps

to damage to the trabecular meshwork during the

are sutured back by 7-0 or 8-0 prolene sutures.

primary trauma.

• The sclerotomies are then closed by 7-0 vicryl and

conjunctiva is closed.

LENS DECENTRATION AND LENS TILT

Advantages of Posterior Approach in

There can occur some amount of lens decentration and

tilt during the placement of the SFIOL in the sulcus and

Traumatized Eyes

while tying the sutures to the sclera. Sometimes, the

More often than not, there is some amount of posterior

sutures can be loose causing an inferior subluxation of

segment involvement due to the primary trauma. There

the IOL. This can cause significant glare or diplopia. The

can be posterior dislocation of the lens or IOL into the

lens can also get tilted during the tying of the sutures or

vitreous which needs to be removed. In other cases,

due to passage of sutures at different levels in the sclera

there can be incarceration of the vitreous into the wound

on the two sides. The incidence of this complication is

which can be a source of traction on the retina and

lesser in SFIOLs fixed to sclera by the 4 point fixation

hence needs treatment. There may be associated

technique and by the ab-externo technique. However,

vitreous hemorrhage which needs vitrectomy if present

some amount of lens tilt is very well tolerated by the

since a long time. Also, retinal breaks and dialysis are

patients with glasses and in clinical practice does not pose

fairly common after closed globe injuries which may

a big problem. However, lens subluxation needs

not be always be possible to see during the preoperative

treatment if the patient is symptomatic.

period due to either vitreous hemorrhage or due to

a non-dilating pupil due to posterior synechiae or due

RETINAL DETACHMENT

to a corneal scar. These can be better visualized and

treated by the posterior approach. Posterior vitreous

It is a rare complication than can occur in any

detachment is almost universal in traumatised eyes.

complicated cataract surgery including SFIOL. This can

98

Clinical Diagnosis and Management of Ocular Trauma

be prevented by doing a good preoperative evaluation

and a good intraoperative fundus examination to

identify any breaks and treat them.

CHOROIDAL DETACHMENT

It a very rare complication but can occur. There can

be a leak from the site of entry of the 27G needle

or from a leaking sclerotomy leading to hypotony. This

can be managed by countering the hypotony by

injecting intraocular air or saline and by a course of

oral steroids.

UVEITIS

Fig. 18.2: Site of scleral tunnel for insertion of SFIOL and

It is more commonly seen in SFIOLs operated from

partial thickness scleral grooves for 10–0 prolene sutures

the anterior route in which vitrectomy is incomplete

and this leads to constant irritation of the vitreous

leading to uveitis. Trauma itself can lead to some

amount of uveitis. This can be managed by adequate

vitrectomy ensuring the lens is free of vitreous and

by using topical steroids in the postoperative period.

ENDOPHTHALMITIS

The 10-0 prolene suture forms a tract for the micro

organisms to gain entry into the posterior segment

leading to endophthalmitis. The knot of the suture also

provides a nidus for the proliferation of organisms.

There can occur delayed endophthalmitis or in some

cases even acute endophthalmitis. This can be

Fig. 18.3: Technique of passing 10–0 Prolene suture: 10–

prevented by adequately rotating the knot in the scleral

0 prolene passed through one end of scleral groove,

bed or by covering it with a scleral flap. In established

engaged out through another scleral groove with help of

cases, intravitreal antibiotics and topical antibiotics can

27 G, 1 inch needle bent at the tip

be started.

SUTURE EROSION

This is again a rare complication but possible. The

knot can erode through the scleral bed and can be

constant source of irritation leading to foreign body

sensation, pain, watering, and discomfort. The knot

can provide a nidus for micro-organisms and cause

an endophthalmitis. If there complete erosion of

Fig. 18.4: Passing of suture through IOL islet in SFIOL haptics

suture, it can break and the lens can dislocate in which

case the procedure may have be repeated. Suture

erosion can be prevented by burying the knot in the

Fig. 18.1: Applied anatomy for SFIOL

sclera and/or covering it with scleral flap. This should

Iris Prolapse

CLINICAL PROFILE OF A PATIENT WITH

IRIS PROLAPSE

INTRODUCTION

History

• The iris is a sensitive tissue in the eye. At the time

The iris is a thin, colored diaphragm that is situated

of an iris prolapse, patients often experience pain.

anterior to the lens. Although the root of the iris is

Patients with a perforated corneal ulcer frequently

attached to the ciliary body, the rest of the iris is

provide a history of severe pain that has since

unsupported. In the event of a corneal wound, the

subsided.

iris tends to prolapse out. Iris prolapse occurs when

• The iris can prolapse after surgery (e.g. cataract,

the iris tissue is observed outside of the wound; iris

corneal transplant), following trauma (e.g. corneal

incarceration occurs when the iris tissue reaches the

laceration, scleral laceration), through a perforated

wound without prolapsing outside the eye. Iris prolapse

corneal ulcer, or through a corneal melt associated

can occur secondary to cataract surgery also.

with rheumatoid arthritis.

• However, the commonest cause by and large of

PATHOPHYSIOLOGY

iris prolapse is the ocular trauma.

Iris prolapse can occur when the cornea is perforated

Signs

due to any cause. In 1995, using flow mechanics and

In peripheral iris prolapse, the iris appears as a knuckle

the Bernoulli principle, Allan provided a theoretical

of colored tissue, resulting in a partial peripheral

explanation of iris prolapse. With a corneal perforation,

synechia. When the prolapse is central, the entire

the aqueous humor rapidly escapes, and a relative

pupillary margin may prolapse, resulting in a total

vacuum is created in front of the iris, thus leading to

anterior synechia. In patients with a perforated cornea,

iris prolapse. Prolapsed iris tissue can be healthy or

the prolapsed iris is exposed.

inflamed or infected or epithelialized with inflammatory

Depending on the duration of prolapse, the

membrane or with conjunctival tissue. Depending on

appearance of the iris may vary. In cases of recent

the status of the prolapsed iris tissue, the iris is either

prolapse, the iris appears viable. With time, the iris

reposited or abscessed or left untouched.

appears dry and nonviable. In patients who have

undergone corneal transplant surgery or cataract

MORTALITY/MORBIDITY

surgery with a clear corneal incision, the appearance

of the iris is the same as in a perforated cornea. When

Iris prolapse is a serious condition and, if left

the iris prolapses through a scleral wound, it appears

untreated, can result in infection and loss of the eye.

as a colored mass beneath the overlying conjunctiva.

It acts as nidus for infection and route of entry for

In this case, the iris remains viable for a long time.

microorganisms to enter into the eye. If the prolapsed

The pupil appears peaked in the region of the iris

iris is exposed (e.g. corneal laceration), immediate

prolapse. The anterior chamber is formed as the

surgical intervention is needed because infection can

prolapsed iris seals the wound. Minimal or no wound

spread through the iris and into the eye. If the prolapsed

leakage occurs. Wound leak is verified using the Seidel

iris is covered by the overlying conjunctiva (e.g. surgical

test. A drop of 2% fluorescein sodium is instilled in

wound), immediate surgical intervention is usually not

the conjunctival sac. The wound is examined under

needed.

the slit lamp with cobalt blue light. The fluorescein

Iris Trauma

101

appears greenish. Wound leak can be easily identified

No eye drops or ointment should be applied in

when the fluorescein is diluted by the aqueous humor.

open eyes with prolapse iris. Intravenous antibiotics

Gentle pressure on the eye may be needed to induce

should be considered because infection from an iris

leakage.

prolapse can spread to the intraocular contents. Broad

However, whenever the iris tissue is plugging the

spectrum antibiotics are recommended. Tetanus toxoid

internal lip of corneoscleral wound, the Siedel’s test is

may be considered depending on the immunization

of no significance, as it will be false negative mainly

status and the wound type.

because of the iris and inflammatory membrane pluging

Surgical Care

the internal lip of corneal or corneoscleral wound.

Intraocular pressure is lower than normal, but

Prompt surgical management is necessary when

hypotony is uncommon after iris prolapse.

conjunctival coverage is not present or in the presence

In long-standing iris prolapse, chronic iridocyclitis,

of complications. The primary goal of surgery is to

cystoid macular edema, or glaucoma may be seen.

restore the anatomical integrity of the eye. Visual

The prolapsed iris may act as a scaffold for infection,

restoration is only a secondary goal.

epithelial downgrowth, or fibrous ingrowth. Rarely,

General anesthesia should be used during surgery.

sympathetic ophthalmia may occur. Carefully

Retrobulbar anesthesia and peribulbar anesthesia are

examining the fellow eye for flare and cells is important

not recommended because they increase both

to rule out sympathetic ophthalmia.

intraorbital pressure and loss of additional intraocular

tissue; however, they may be used if general anesthesia

Lab Studies

is contraindicated.

Iris prolapse is a clinical diagnosis.

Through a paracentesis incision, a viscoelastic agent

is injected into the anterior chamber in the region of

Imaging Studies

the iris prolapse. This mechanical force may be enough

to release the prolapse and to reposition the iris.

• In long-standing iris prolapse, if cystoid macular

If the viscoelastic method is unsuccessful, then a

edema is suspected, fluorescein angiography may

cyclodialysis spatula with the longer end is introduced

be performed. Cystoid macula edema appears as

through the paracentesis incision. The spatula is swept

a flower petal in the late stages of the angiogram.

from the center to the periphery of the prolapse to

• CT scan of the orbits is indicated with traumatic

avoid unnecessary tension on the iris root. The corneal

iris prolapse to aid in diagnosing other ocular and

wound may be sutured depending on its length and

orbital trauma and especially if the history is

integrity.

suggestive of intraocular foreign bodies.

If the prolapse occurred within the previous 24-

• In traumatic iris prolapse, ocular ultrasound may

36 hours and if the iris is viable, the iris is reposited.

be gently performed by experienced personnel.

The sings of viable iris tissue are glistening iris tissue

This imaging modality may help to locate

with no inflammatory membranes on surface of iris

intraocular foreign bodies and to assess the status

tissue. The texture and glow of iris tissue are the

of the posterior segment of the eye. Care should

important indicators for viability of iris tissue.

be taken while performing the ocular ultrasound

If the iris does not appear viable, then it is abscised.

because undue pressure can cause prolapse of the

The iris should be abscised if signs of epithelialization

intraocular contents.

are present. The abscission involves pulling of the iris

TREATMENT

tissue and cutting some part of normal healthy iris tissue

Conservative Treatment

along with non-viable iris tissue which is prolapsed out.

The excision involves just cutting the prolapsed iris tissue

Iris prolapse is a serious condition that requires prompt

flushing through the corneal surface.

medical management. As soon as the diagnosis is made,

If the iris prolapse occurs after surgery, the same

an eye shield should be applied to prevent further

principle is used. The wound must be revised, or

damage. One should try and avoid pressure patch over

additional sutures should be applied to make the wound

the traumatized eye as the pressure patch by itself can

watertight.

act as nidus for infection and with the eye being closed,

When the iris prolapse occurs after a corneal

the organisms can flourish inside the closed eye.

perforation, the iris can be reposited. Cyanoacrylate

Medical treatment is only indicated when the

glue and a bandage contact lens may be used to seal

prolapse is small, is covered by the conjunctiva, and

the perforation. If unsuccessful or if the perforation

is without any other complications. In these cases, the

is large, an emergency corneal patch graft or corneal

eye may be observed.

transplant is necessary.

102

Clinical Diagnosis and Management of Ocular Trauma

Holistic Approach

TREATMENT AND MANAGEMENT

In patients with a corneal melt due to medical causes

In our enlightened age of small incision, closed-system

(e.g. rheumatoid arthritis), appropriate consultations

anterior segment surgery, we have increased surgical

must be obtained.

control over the intraocular environment and have

developed the skills for more sophisticated iris repair.

Iridodialysis

Simultaneously, we are more attentive to glare and

photophobic complaints from our cataract and

INTRODUCTION AND CAUSES

refractive surgery patients. The confluence of increased

awareness and surgical abilities set the stage for the

Iridodialyses, sometimes known as a coredialysis, is a

new epoch in iris surgery.

localized separation or tearing away of the iris from

Iridodialysis causing an associated hyphema has to

its attachment to the ciliary body, are usually caused

be carefully managed, and recurrent bleeds should

by blunt trauma to the eye, but may also be caused

be prevented by strict avoidance of all sporting

by penetrating eye injuries. An iridodialysis may be

activities. Management typically involves observation

an iatrogenic complication of any intraocular surgery

and bed rest. Red blood cells may decrease the outflow

and at one time they were created intentionally as part

of aqueous humor, therefore the eye should be kept

of intracapsular cataract extraction. Iridodialyses have

soft by giving oral acetazolamide. Accidental trauma

been reported to have occurred from boxing, airbag

during sleep should be prevented by patching with

deployments, high-pressure water jets, elastic bungee

an eye shield during night time. Avoid giving aspirin,

cords, bottle caps opened under pressure, water

heparin/warfarin and observe daily for resolution or

balloons, fireworks, and various types of balls.

progression. A large hyphema may require careful

SYMPTOMS AND SIGNS

anterior chamber washout. Rebleeds may require

additional intervention and therapy.

Abnormal pupils affect patients in several ways,

Later, surgical repair may be considered for larger

including photophobia and glare. These patients often

avulsions causing significant double vision, cosmesis

describe discomfort or difficulty in brightly lit areas,

or glare symptoms. Surgical repair is usually done by

such as supermarkets, or on sunny days. Typically, they

10-0 prolene suture taking the base of iris avulsion

report that sunglasses do not alleviate their symptoms

and suturing it to the scleral spur and ciliary body

either outside or indoors. Edge glare from an exposed

junction.

intraocular lens optic margin can elicit similar complaints

SURGICAL PLANNING

and may induce disturbing crescents, arcs of light, “tails”

on lights and other optical aberrations.

Like most intraocular procedures, repairing a damaged

Rarely, an irregular pupil may induce an undesired

iris requires preoperative planning and meticulous

refractive effect. Since the visual axis usually goes

technique. With careful attention to detail and basic

through the geometric center of the pupil, the visual

principles, you can master the art of iris repair.

axis-corneal intercept may be abnormally placed

Preoperatively, you must determine whether there

through an area of irregular corneal topography.

is sufficient iris tissue remaining to achieve the desired

Those with small iridodialyses may be asymptomatic

goals. It is often difficult to assess how much tissue is

and require no treatment, but those with larger dialyses

present because the iris stroma may be contracted or

may have corectopia or polycoria and experience

rolled over. Careful examination and review of prior

monocular diplopia, glare, or photophobia. Iridodia-

operative notes are helpful in determining whether

lyses often accompany angle recession and may cause

tissue has been removed. Typically, there is more iris

glaucoma or hyphema. Hypotony may also occur.

present than you might think based on slit-lamp

An abnormal pupil may also have deleterious

examination.

psychosocial effects. As a society, we place a psychic

Furthermore, iris tissue is usually very stretchable

premium on the appearance of the eyes. It is common

and can cover larger areas than you might initially

for people to make instant judgments about others

anticipate. Usually, if the patient retains two-thirds or

based on how their eyes look. A shifty gaze, for

more of normal iris tissue, surgical repair can produce

example, may be interpreted as dishonest. If people

a good functional and anatomic result. For cases in

are uncomfortable looking into the eyes of a person

which large amounts of iris tissue is absent, artificial

with an abnormal iris, that can play an important role

iris diaphragms, overlapping rings or sectoral implants

in that individual’s interpersonal interactions and,

may be a more appropriate option to augment the

perhaps, affect his self-esteem.

remaining native iris tissue.

Iris Trauma

103

PRINCIPLES OF IRIS REPAIR

minimizes iris traction. This technique allows the knot

The basic principles of iris repair are fairly straight-

to slide into the anterior chamber without pulling iris

forward. First, instillation of a miotic agent such as

tissue to the wound margin and without cumbersome

pilocarpine, puts the iris stroma on maximal stretch,

intracameral knot-tying maneuvers. Once the suture

increasing the surface area. Intracameral manipulations

has been passed, place a Kuglen hook through the

should be performed under viscoelastic agents to

initial paracentesis tract, engage the suture just beyond

prevent chamber volatility, iris stretching and corneal

the distal iris pass and draw a loop of suture out through

endothelial damage. When choosing your viscoelastic

the paracentesis site. Maintaining proper orientation

agent, remember that you may be removing it

of the sutures is of utmost importance in creating a

manually through a small incision. Highly retentive

knot. The orientation should be:

agents may be difficult to remove without automated

1.

Trailing suture strand;

irrigation and aspiration, while retained bits of overly

2.

Part of loop from distal iris pass and;

viscous materials can cause a significant postoperative

3.

Part of loop exiting peripheral cornea.

intraocular pressure rise. The very soft and friable

If the loop folds over and changes the relative

consistency of the iris demands an atraumatic

position of 2 and 3, a twist occurs instead of the

technique. Often, posterior or peripheral anterior

intended knot. Pass the trailing suture around the

synechiae prevent proper mobilization of the iris

middle arm of the loop twice. Then gently draw

leaflets. Therefore, gentle blunt or sharp synechiolysis

together the trailing strand and the exited strand on

may be the first step in repair. When the sphincter

the opposite side of the eye, pulling the two iris leaflets

is involved in the injury or damage, reapposing the

together and creating the first throw of a knot. Retrieve

severed pupil margin establishes a central pupil and

the suture loop a second time for a single locking throw

creates a more taut iris diaphragm, facilitating further

and trim the knot.

steps.

Repair of Iridodialysis

Because patients may develop glare symptoms

when the optic margin of an implant lens is exposed,

Iridodialysis and iris repair share similar principles and

the repaired iris leaflets should cover all IOL edges.

some similar techniques, with a few caveats. Use a

When an implant placement or exchange is performed

double-armed suture. In a similar closed-chamber

coincident with iris repair, a larger optic implant may

approach, I engage the peripheral iris margin with the

facilitate this task.

first needle tip and pass the suture through the scleral

wall at the level of the iris root. I pass the second needle

Suture Placement

through the same paracentesis and engage the

Suture and needle choices are up to the surgeon’s

peripheral iris root about one to two clock hours away.

The second needle is similarly passed out the sclera

preference. With a long track record in the anterior

and the suture is tightened and tied externally, drawing

segment, the prolene suture appears resistant to

the peripheral iris to the scleral wall. The knot is

hydrolysis in the anterior chamber and, therefore, may

trimmed and rotated internally.

be a better choice than nylon.

The needle enters the anterior chamber via a

Iris Implants

conveniently placed paracentesis site. The paracentesis

should be large enough to allow easy ingress of a

When significant amounts of iris tissue are damaged

Kuglen hook. Take special care to avoid catching any

or missing, iris repair may be impossible. In these eyes,

corneal fibers as the needle passes through the

artificial iris implants can augment the iris diaphragm,

paracentesis tract. The sharp-tipped needle passes

thereby reducing photophobia and glare. A variety

through the iris with a minimum of countertraction

of artificial implant designs are available in Europe and

and minimal iris tearing. The long, curved shape

elsewhere, though currently none are Food and Drug

permits passage of the needle in a closed-chamber

Administration approved for use in the United States.

fashion through a paracentesis. The proximal iris leaflet

The currently manufactured iris implants come in five

is engaged by the needle tip, then the distal iris leaflet.

categories:

The needle is then passed out through the peripheral

1. Large diameter, rigid iris diaphragms with or

cornea.

without a central optic (Morcher GMBH, Germany

Suture Tying

and Ophtec, The Netherlands).

2.

Overlapping, interdigitating iris rings (Morcher).

Tying the suture with the sliding knot technique

3.

Capsular tension rings with opaque iris segments

(introduced to ophthalmology by Steven Seipser, MD)

(Morcher).

Iris Trauma

105

4. Intracapsular Hermeking iris prosthetic system

4.

Brown SM. “A technique for repair of iridodialysis in

implants (Ophtec).

children.” J AAPOS. 1998;2(6):380-2. PMID 10532731.

5.

Cassin B, Solomon S. Dictionary of Eye Terminology.

5. Custom iris implants with enclavation fixation

Gainsville, Florida: Triad Publishing Company 1990.

(Ophtec).

6.

Cline D, Hofstetter HW, Griffin JR. Dictionary of Visual

Science. 4th ed. Butterworth-Heinemann, Boston

COMPLICATIONS

7.

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Those with traumatic iridodialyses particularly by blunt

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