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CONTRIBUTING AUTHORS
Ashar Agarwal, MS, FRCS (Chapters 5 and 12)
Dr.Agarwal’s Group of Eye Hospitals and
Eye Research Centre
Chennai, India
Athiya Agarwal, MD, DO (Chapter16)
Dr.Agarwal’s Group of Eye Hospitals and
Eye Research Centre
Chennai, India
Masayuki Akimoto, MD, PhD
(Chapter 10 Case Presentation 2)
Osaka Red Cross Hospital
Osaka, Japan
BrandonD. Ayres, MD (Chapters4 and 14)
Co-Director
Cornea Fellowship
Cornea Service
Wills Eye Hospital
Philadelphia, Pennsylvania
SonalS. Chaugule, MS (Chapter16)
Department of Ophthalmic Plastic Surgery,
Orbit and Ocular Oncology
PBMA’s H. V. Desai Eye Hospital
Pune, India
RobertJ. Cionni, MD
(Chapter3 Case Presentation)
Director
Moran Eye Center
Department of Ophthalmology
University of Utah
The Eye Institute of Utah
Salt Lake City, Utah
AlanS. Crandall, MD (Chapter2)
Moran Eye Center
University of Utah
Salt Lake City, Utah
Paul T. Fing er, MD (Chapter 16)
Clinical Professor of Ophthalmology
Director
New York Eye Cancer Center
New York, New York
SadeerB. Hannush, MD
(Chapter5 Case Presentation 2)
Attending Surgeon
Cornea Service
Wills Eye Hospital
Professor of Ophthalmology
Sidney Kimmel Medical College
Thomas Jefferson University
Medical Director
Lions Eye Bank of Delaware Valley
Philadelphia, Pennsylvania
RichardS. Hoffman, MD (Chapter6)
Clinical Associate Professor of
Ophthalmology
Casey Eye Institute
Oregon Health and Science University
Portland, Oregon
Santosh G. Honavar, MD, FACS, FRCOphth
(Chapter16)
Director
Ophthalmic Plastic Surgery and Ocular
Oncology
Centre for Sight
Hyderabad, India
Dhivya Ashok Kumar, MD, FRCS, FICO, FAICO
(Chapters1 and 16)
Dr.Agarwal’s Group of Eye Hospitals and
Eye Research Centre
Chennai, India
Ravi Kumar K V, PGDO, FCO (LVPEI),
FICO (SWISS) (Chapter6 Case Presentation 2)
Former Chief Medical Officer
Rotary Eye Hospital
Vuy yuru, India
Mami Kusaka, MD
(Chapter10 Case Presentation 2)
Department of Ophthalmology and
Visual Sciences
Graduate School of Medicine
Kyoto University
Kyoto, Japan
Yuri McKee, MD (Chapter3)
East Valley Ophthalmology
Mesa, Arizona
xx Contributing Authors
KevinM. Miller, MD (Chapter9)
Kolokotrones Chair in Ophthalmology
Chief
Cataract and Refractive Surgery Division
Director
Anterior Segment Diagnostic Laboratory
David Geffen School of Medicine
University of California, Los Angeles
Stein Eye Institute
Los Angeles, California
Vladimir Pfeifer, MD, FEBOS-CR
(Chapter9 Case Presentation 3)
Chief
Cornea and Refractive Surgery Service
Head
Ljubljana Eye Bank
University Eye Hospital
Director
Eye Surgery Center
Ljubljana, Slovenia
StevenG. Safran, MD
(Chapter 2 Case Presentation)
Capital Health System
Pennington, New Jersey
Penn Medicine Prince ton Medical Center
Prince ton, New Jersey
New Jersey Surgery Center
Mercerville, New Jersey
MichaelE. Snyder, MD
(Chapter9 Case Presentation 2)
Clinical Governance Board Member
Chair
Clinical Research Steering Committee
Cincinnati Eye Institute
Professor of Ophthalmology
University of Cincinnati
Cincinnati, Ohio
WilliamB. Trattler, MD (Foreword)
President
Center for Excellence in Eye Care
Volunteer Faculty
Florida International University College of
Medicine
Miami, Florida
Claudio Trindade, MD, PhD (Chapter15)
Board of Directors
Cançado- Trindade Eye Institute
Belo Horizonte, Brazil
DavidT. Truong, MD (Chapter9)
Eye Associates of New Mexico
Albuquerque, New Mexico
Shin Yamane, MD, PhD
(Chapter8 Case Presentation 2)
Yamane Eye Clinic
Hiroshima, Japan
PREFACE
This book goes beyond basic teachings, presenting surgical knowledge that can help enhance
surgical potential and avoid therapeutic missteps. Princi ples of surgical management of iris anomalies and defects are presented with the intention to help polish the arsenal of discreet medical
and surgical facts.
The book is divided into 3 parts: SectionI discusses the basics of vari ous iris repair techniques;
SectionII features special topics that set a framework for managing iris repair; and SectionIII
addresses the extended implications of iris repair. Each of the 16 chapters is abundantly referenced,
pre sents evidence-ba sed cases, and has video content. The case prese n tati on in each chapter allows
the reader to think further about the implications of surgical procedure and treatment.
The editors of this book have made extensive effort to ensure that the information is accurate
and is useful to surgeons.
Ashvin Agarwal, MBBS, MS
Amar Agarwal, MS, FRCS, FRCOphth
Priya Narang, MS
FOREWORD
Mastering Iris Repair— the title describes exactly what readers can expect to achieve after reading the chapters and learning from the outstanding videos or ga nized by 3 pioneers of this field.
Surgical repair of the iris pre sents significant challenges to even experienced anterior segment
surgeons. The editors, Ashvin Agarwal, MBBS, MS; Amar Agarwal, MS, FRCS, FRCOphth;
and Priya Narang, MS, along with the contributing authors, have developed a curriculum of book
chapters and videos that will enable surgeons to manage the iris with new insights and understanding. This is a must-r ead book for surgeons who want to excel in the area of iris repair.
The editors are gifted surgeons and educators. Dr.Narang and Dr.Amar Agarwal, in par ticu lar, have developed innovations that have profoundly impacted iris repair. They developed the
single- pass four- throw pupilloplasty technique, which significantly simplifies surgical repair of
the iris. Dr.Amar Agarwal also developed the pinhole pupilloplasty technique, which dramatically improves vision in patients with vision loss related to the cornea.
Beyond this book, the editors have helped me learn a variety of surgical skills that allow me to
provide better care for my patients. Their vast experience in iris repair has been generously shared
in many lectures that have taught surgeons the pearls and pitfalls of surgical repair of the iris.
The editors have invited world experts to contribute to the chapters and videos. These contributing authors make this an impressive book for young surgeons who want to learn more about
surgical repair of the iris as well as experienced ophthalmic surgeons who would like to refine their
skills to optimize surgery for their patients.
In summary, I would like to congratulate the editors for their hard work developing this
extremely valuable book on iris repair. As ophthalmic surgeons, we will learn the variety of surgical techniques and tips to provide advanced surgical treatments for patients who require surgery
on the iris.
WilliamB. Trattler, MD
SECTION I
IRIS REPAIR TECHNIQUES
1
Introduction, Indications,
and Salient Points
ofٶIrisٶTissue and Repair
Dhivya Ashok Kumar, MD, FRCS, FICO, FAICO and
Amar Agarwal, MS, FRCS, FRCOphth
KEYWORDS
cerclage, iris repair, McCannel, pupilloplasty, Siepser technique,
single-pass four-throw pupilloplasty, uvea
The pigmented iris tissue imparts the unique color to human eyes and is a part of the uvea,
which is a highly vascular structure. The iris is a thin, soft structure that forms the entrance
pathway, or pupil, through which light enters the eye. The iris tissue along with the lens acts as
a vital diaphragm between the anterior and the posterior segments of the eye. The iris tissue can
be injured in blunt or penetrating trauma causing subsequent iris defects. Congenital iris defects
like coloboma or aniridia have also been reported. Being part of uveal tissue, it is antigenic and
can also induce inflammation as it harbors pigment cells. Iris reconstruction and repair has been
performed for vari ous clinical conditions.
optical (to improve quality of vision), functional (to improve visual acuity), structural (to reattach
iris in its anatomical position), and cosmetic (to maintain pupil contour, iris color, and configuration). In this chapter, we will be highlighting the basics of applied anatomy, history, common
repair principles, and key points of iris repair.
1-16
Iris reconstruction may fall broadly into 4 categories:
ANATOMY OF THE IRIS
The iris is the anteriormost part of the uvea that forms a thin circular diaphragm dividing the
eye into anterior and posterior chambers. Its diameter is a round 12mm, while its thickness varies.1 It is thinnest at its root, where it is attached to the anterior surface of the ciliary body, and
Agarwal A, Agarwal A, eds. Mastering Ir is Repair:
© 2021 Taylor & Francis Group.
DOI: 10.1201/9781003525028-2
- 3 -
A Video Textb ook of Iri s Repair and Pupilloplasty Techniques (pp 3-12).
4 Chapter 1
Figure 1-1. Clinical image
showing the normal
architecture of iris (arro
indicates crypts).
Figure 1-2. High magnification image of iris showing
collare
tte (blue line), furrows (black arrow), Fuch’s crypts
(white dotted arrow), and pupillary frill or ruff (white
arrow).
w
thickest at about 2mm from the pupillary margin, where it is called the collarette (Figure1-1).1
The collarette divides the anterior surface of the iris into 2 zones— the ciliary zone and pupillary
zone. The ciliary zone has a velvety surface with characteristic radial streaks, crypts, and contraction furrows (Figure1-2). The radial streaks are trabeculae, or bands of connective tissue, formed
by radiating blood vessels from the major arterial circle. A few oval- shaped depressions, called
Fuch’s crypts, are more pronounced near the collarette. They are enclosed by the bands of radial
streaks. Contraction furrows are concentric lines around the collarette that are more vis i ble when
the pupil dilates. The pupillary zone is relatively smooth and flat except at the pupillary border
where the iris posterior pigmented epithelium extends slightly anteriorly to form the pupillary frill.
The posterior surface of the iris is dark with multiple radial contraction folds and circular furrows.