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Twofold Technique for Iridodialysis Repair 105
Figure10-14.Part 4: Illustration showing the hang-back technique for iridodialysis.
(A) Both suture ends are pulled, which retracts the iris. (B) Iris getting retracted. (C)
Apposition of the iris to the sclera. (D) Suture tied.
Figure 10-15. Part 1: Illustration showing the SFT pupilloplasty technique. (A) To
correct the updrawn pupil, a 10- 0 Prolene suture attached to the needle is passed
through the proximal iris tissue. (B) A 26/30-g auge needle is passed from the
paracentesis incision from the opposite side in a way that it engages the distal iris
tissue to be approximated. (C) The 10-0 needle is threaded into the barrel of the
26-g auge needle and the needle is pulled out of the anterior chamber. (D) Suture
being pulled out through the paracentesis.
106 Chapter 10
Figure 10-16. Part 2: Illustration showing the SFT pupilloplasty technique. (A) The
loop of the suture is created using a dialer. (B) The loop of the suture is pulled on
using the glued IOL forceps. (C) The loop of the suture is withdrawn from the anterior
chamber. (D) Four throws are started on the loop that is outside.
Figure 10-17.Part 3: Illustration showing the SFT pupilloplasty technique. (A) The
suture end is passed from the loop 4 times. (B) The knot is slid into the eye by pulling
at both ends. (C) SFT is completed and the ends of the suture cut with micros cissors.
(D) Same SFT procedure is performed at the other end to get a well- shaped pupil.
Twofold Technique for Iridodialysis Repair 107
Figure 10-18.Illustration of twofold technique for moderate iridodialysis. (A) The image shows a moderate
amount of iridodialysis. (B) A SFT procedure is being performed along the edge of the base of the iris tissue.
A 10-0 suture on long-armed needle is passed from one side and a 26- gauge needle is passed from the
corresponding iris tissue on the other side. (C) The 10-0 needle is threaded into the 26-g auge needle and is
withdrawn from the anterior chamber. A loop of the suture is withdrawn from the anterior chamber and the
suture end is passed from the loop taking 4 throws. (D) Both the suture ends are pulled and the iris tissue is
approximated. The suture ends are cut with micros cissors. Note the narrowing of the iridodialysis defect. (E) A
10-0 double- armed suture on a long needle is passed to reappose the peripheral iris defect with the hangback technique. (F) The peripheral iris defect is sealed. (Republished with permission of Elsevier, from Narang
P, Agarwal A, Agarwal A, Agarwal A. Twofold technique of nonappositional repair with single-pass four-throw
pupilloplasty for iridodialysis. J Cataract Refract Surg, 44[12];2018; permission conveyed through Copyright
Clearance Center, Inc.)
108 Chapter 10
Figure10-19.Part 1: Twofold technique for moderate to minimal iridodialysis. (A) A
10-0 suture attached to a long-armed needle is passed from the proximal iris tissue
defect and the needle is threaded into the barrel of 26/30-g auge needle introduced
from the opposite side that engages the distal iris tissue that is to be apposed. This
is the railroad technique. (B) The suture loop is withdrawn from anterior chamber.
(C) Four throws are taken through the loop. (D) Both the suture ends are pulled and
the iris defect is narrowed down to a great extent. The suture ends are then cut with
micros cissors. (Republished with permission of Elsevier, from Narang P, Agarwal A,
Agarwal A, Agarwal A. Twofold technique of nonappositional repair with singlepass four-throw pupilloplasty for iridodialysis. J Cataract Refract Surg, 44[12];2018;
permission conveyed through Copyright Clearance Center, Inc.)
Twofold Technique for Iridodialysis Repair 109
Figure10-20.Part 2: Twofold technique for moderate to minimal iridodialysis. (A) A
non-appositional repair is being performed and a 10-0 long-armed needle is passed
from the paracentesis incision in a way that it engages the peripheral iris tissue that
needs to be apposed. (B) The needle is withdrawn from the scleral side. (C) The
second arm of the suture is passed through the adjacent iris tissue and the needle
exits the eye on the scleral side. Both suture ends are tied. (D) The knot is formed and
then buried in the scleral wall. (Republished with permission of Elsevier, from Narang
P, Agarwal A, Agarwal A, Agarwal A. Twofold technique of nonappositional repair
with single-pass four-throw pupilloplasty for iridodialysis. J Cataract Refract Surg,
44[12];2018; permission conveyed through Copyright Clearance Center, Inc.)
110 Chapter 10
Figure 10-21. Part 1: Illustration of twofold
technique for moderate to minimal iridodialysis.
(A) A case of minimal iridodialysis. (B) A 10-0 suture
attached to a long-armed needle is passed through
the iris defect. (C) The needle is threaded into the
barrel of a 26/30- gauge needle introduced from the
opposite side that engages the distal iris tissue that
is to be apposed. (D) This is the railroad technique.
Figure 10-22. Part 2: Illustration of twofold
que for moderate to minimal iridodialysis.
techni
(A) Railroad technique completed. (B) The suture
loop is withdrawn from the anterior chamber. (C)
Four throws are taken through the loop. (D) Both
the suture ends are pulled and the iris defect is
narrowed down substantially. The suture ends are
then cut with micro scissors.
Figure 10-23. Part 3: Illustration of twofold technique for moderate to minimal iridodialysis. (A) The doublearmed 10-0 polypropylene suture attached to a long-armed needle is passed through the peripheral iris tissue via
a paracentesis. (B) The needle is brought out through a scleral groove. (C) The suture is brought out through the
sclera and the other arm of the double -needle is also passed the same way. (D) The 2 ends of the suture are tied. T he
hang-back technique is repeated on the other side. (E) Hang-back technique. (F) Suture tied and the pupil restored.
Twofold Technique for Iridodialysis Repair 111
Figure10-24.Minimal iridodialysis.
DISCUSSION
Iridodialysis repair is an essential component to restore the architecture and integrity of the
iris tissue (Figure10-24). The twofold technique includes of all the advantages of the non-appositional technique and the SFT technique. The advantage of the non-appositional technique is
not damaging the trabecular meshwork because the iris tissue does not cover the anterior chamber
angle. This avoids the possibility of developing a secondary angle closure. SFT has the presumed
advantage of inducing less inflammation and less pigment dispersion because it avoids unnecessary
intervention in the anterior chamber. To summarize, the twofold technique facilitates iridodialysis
repair and allows for correction of corectopia, thereby preventing glare and photophobia.
112 Chapter 10
Figure 10-25. Part 1: Illustration of trocarassisted hang-back technique. (A) Case
demonstrating iridodialysis. (B) A 25-gauge
trocar is introduced from the limbus from
the opposite quadrant. (C) The trocar blade
is withdrawn and the cannula is snugly fit.
(D) A 10-0 polypropylene suture attached
to the long-armed needle and is introduced
from the lumen of the cannula.
TROCAR-ASSISTED NON-APPOSITIONAL REPAIR
During the iris repair maneuver, incorporation of corneal tissue into the suture needle leads
to non-sliding of suture inside the eye. In order to overcome this aspect, trocar-assisted repair is
proposed for performing an iridodialysis repair with non-appositional method. A 25-gauge trocar
is placed inside the eye that is introduced from the limbus in the quadrant opposite to the area of
iridodialysis. The 9-0 suture needle is passed through the trocar followed by engagement of the
peripheral disinserted iris tissue. A 30-gauge needle is introduced from the scleral side and the
suture needle is threaded into it and withdrawn from the eye. The second arm of the suture is
again passed in the similar way engaging the area of adjacent iris tissue to the previous pass. Once
both the suture needles are withdrawn, the loop of suture is pulled on the scleral side and a knot
is tied and buried inside the scleral wall (Figures 10-25 through 10-27).
Twofold Technique for Iridodialysis Repair 113
Figure 10-26. Part 2: Illustration of trocarassisted hang-back technique. (A)The suture
needle engages the rim of the peripheral iris
tissue. (B) A 30-gauge needle is introduced
from the scleral side and the suture needle
is threaded into the barrel of the needle. (C)
The 30-gauge needle that eventually pulls
the suture along with it is withdrawn. (D) The
second arm of the double-needle suture is
similarly passed through the cannula and
engages the iris rim adjacent to the previous
pass. The suture is again threaded into the
30-gauge needle.
Figure 10-27. Part 3: Illustrated description
of trocar-assisted hang-back technique.
(A) The suture needle passes through the
sclera. (B) Both suture ends are pulled. (C) The
suture engages the peripheral iris tissue and
it lies in close approximation to its insertion.
(D) Both the suture ends are tied and a knot
is formed.
114 Chapter 10
CASE PRE SEN TA TION 1
TWOFOLD TECHNIQUE FOR IRIDODIALYSIS REPAIR
Priya Narang, MS; Ashvin Agarwal, MBBS, MS; and
Amar Agarwal, MS, FRCS, FRCOphth
During cataract surgery, a patient has an intraoperative complication. A posterior capsular
rupture is noted in the initial phase of cataract surgery with non-emulsified nuclear fragments
pre sent in the anterior chamber. Two partial-thickness scleral flaps are made 180 degrees
opposite each other, and sclerotomy is made about 1mm away from the limbus, beneath the
scleral flaps. The tip of the needle hits the iris base and iridodialysis is created. A 3- piece IOL
is injected inside the anterior chamber and an IOL scaffold procedure is performed. After the
nucleus is emulsified the same 3-pie ce IOL is fixed with the glued IOL procedure. The twofold
technique is performed for iridodialysis repair (Figure10-28 and Video 10-2).
Figure 10-28. Tw ofo ld i rid odi aly sis
repair in a case of iatrogenic trauma.
(A) Iatrogenic iridodialysis is observed
during the stage of sclerotomy for glued
secondary IOL fixation. A double- armed
10-0 suture needle is passed from the
peripheral margin of the iris tissue and
the needle is passed on to scleral surface.
(B) Both ends of the double-ar med
suture are passed and pulled through
the scleral side. (C) The SFT procedure
is performed to correct corectopia
induced due to overpull of the iris tissue
during non-appositional repair. (D) Pupil
reconstruction is complete.