Introduction
Iridodialysis is a localized disinsertion of the iris from its attachment to the ciliary body where it is weakest and thinnest.1, 2 It generally occurs due to oculartrauma3 and intraocular procedures such as cataract surgery.4 The incidence of iridodialysis due to small incision cataract surgery stands at 0.2%.5 Intervention might not be required when the dialysis is small, but large and symptomatic iridodialysis frequentlyneeds surgical repair.Superior iridodialysis involving 10 O’ clock to 2 O’ clock positionis often less symptomatic as it is covered by the upper eye lid whereastemporal, inferior and large iridodialysis are usually symptomatic. Numerous techniques for iridodialysisrepair have been described, most of them being technically challenging.4, 6, 7 We describe a simplified approach of iridodialysis repair using 10-0 non absorbable monofilament polyamide suture (Ethilon)and basic instrumentsused for a conventional cataract surgerywith a favourable outcome.
Case Report
A 62 years old male was undergoing cataract surgery in his right eye by a trainee surgeon under the supervision of a senior surgeon. After nucleus delivery a large iridodialysis was noted inferiorly from 4 O’clock to 8 O’clock position- (Figure 1 A, B and Figure 2 A). As the dialysis was large and inferiorly situated, it was decided to repair the iris in the same sitting and planned after the implantation of intra ocular lens.
Figure 1
A): Pre-operative photograph showing an inferior iridodialysis from 4 O’clock to 8 O’clock position (shaded area) and prolapsed iris superiorly through the main wound. Note the D shaped pupil due to iridodialysis; B): Preoperative photograph after iris reposition
Figure 2
Step wise illustration of iridodialysis repair: A): Depiction of Iridodialysis and iris prolapse; B): Three sutures passed from sclera side (5 O’ clock, 6 O’ clock and 7 O’ clock positions) through the corresponding edges of iris and exteriorized through cornea; C): Sutures individually tied in 3-2-2 fashion and rotated inwards to approximate the iris to its insertion
Figure 3
Postoperative picture showing correction of iridodialysis and formation of fairly round pupil centrally
Surgical technique
Following a top up peribulbar anaesthesia, inferior peritomy was done and hemostasis attained with light cautery. A 10-0 non absorbable monofilament polyamide suture (Ethilon) with a curved needle was passed from sclera at 7 O’clock position corresponding to the iris insertion, the inferior edge of the detached iris is taken into the needle with the help of an iris repositor in the anterior chamber and the suture is exteriorized through cornea. The same as above was done at 6 O’ clock and 5 O’ clock positions as shown in Figure 2 B. The three sutures were tied with knots in 3-2-2 fashion. All the knots were rotated into the anterior chamber and pulled towards the angle of anterior chamber so that the knots approximated the edges of the dialysed iris to its insertion as shown in Figure 1 C. The procedure was completed with formation of anterior chamber with balanced salt solution and air followed by closure of peritomy and placement of a bandage contact lens (BCL) over the cornea. Sub conjunctival gentamycin and dexamethasone were delivered to minimise the risk of intra ocular infections and inflammation. The postoperative period was uneventful and the recovery was good. The visual acuity at 2 weeks postoperative period was 6/9 with fairly round pupil and no diplopia and glare.
Discussion
Iridodialysis causes polycoria which can be annoyingly symptomatic due to monocular diplopia and glare. Sometimes it can be cosmetically unacceptable. Iridodialysis can be classified into massive (More than 120 Degrees), moderate (45 to 120 Degrees), and minimal (less than 45 Degrees) depending on the extent of dialysis.8 Characteristically, the functional and cosmetic complaints are often encountered if iridodialysis occurs in the inferior, temporal or nasal aspects. Our patient had a large inferior iridodialysis which would have been symptomatic and caused cosmetic issues. Ever since BW Key described the first iridodialysis repair in 1932, various surgeons have been attempting the procedure with varied results.4, 6, 7, 9, 10, 8, 11, 12, 13, 14 Mc Cannel’s technique initiated a revolution in iris repair among ophthalmic surgeons.7 Sewing machine technique was originally described for iridodialysis subsequently got modified.7, 12, 13 Siepser slip knot,7 mattress suture14 and single pass four throw technique8 have been in vogue. Availability of number of techniques has provided the surgeons with options to choose from. Most of these procedures required straight suturing needles which may not be available in the operation theatre all the time and maneuvers are more complex. Often the anterior chamber could not be maintained stable during large iridodialysis repair. More importantly the iridodialysis repair procedure would have to be planned electively if it occurs during any other intra ocular procedures such as cataract surgery. Our technique was performed on the same sitting with the instruments generally used for conventional cataract surgery. Hence it can be done in camp setup with limited availability of instruments.
The advantages of this simple technique are:
It can be performed with available instruments used for conventional cataract surgery.
Anterior chamber stability is maintained.
Minimal tissue handling.
Our novel and simple technique requires simple maneuvers and results in good functional and cosmetic outcome.
Limitation
The exteriorized suture on the cornea may cause irritation and pose a risk for infection. To address this, we had placed a BCL and the patient was closely monitored. Application of topical antibiotic drops were extended along with regular postoperative medications. Our patient’s post operative period was uneventful.
