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Video Report

Iris Cerclage Suture Technique for Traumatic Mydriasis

Luis E Fernández de Castro, Helga P Sandoval, Kerry D Solomon, David T Vroman

Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA

Correspondence: David T Vroman MD, Magill Research Center for Vision Correction , MUSC-Storm Eye Institute, 167 Ashley Avenue, Charleston, SC 29425, USA. Tel: (843) 792-8861. Fax: (843) 792-1166
Email: vromandt@musc.edu

Date of acceptance: 15th November 2005

A 10-0 polypropylene suture on a curve needle is passed in and out of the anterior chamber through three paracentesis openings while weaving the needle through the iris near the pupillary margin to form the cerclage.

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Introduction

Blunt trauma can result in focal or diffuse sphincter muscle injury producing mild anisocoria with retained pupil reactivity. Mydriatic pupils can be a disabling condition that causes glare, photophobia, and decrease visual acuity.[1]

Multiple techniques for the surgical repair of diffuse sphincter have been described using single or multiple interrupted iris sutures,[2] running sutures using forceps for iris manipulation,[3,4] and running sutures with minimal iris manipulation.[1] The ultimate goal is restore the eye to a more natural and functional anatomic state. We report a case of a traumatic mydriasis managed by iris cerclage suture technique.

 

Case Report

A 44-year-old male was seen for the first time in April 2004 with complaints of fluctuating visual acuity in the right eye. His history revealed that he had a blunt trauma on the right eye two days prior to his initial visit. His injuries included a dislocated lens with 6-7 clock hours of zonular loss, 360° angle recession with traumatic mydriasis at 9.0 mm, vitreous prolapsed into anterior chamber, and vitreous hemorrhage. B-scan ultrasound revealed moderate vitreous debris without retinal detachment. The visual acuity was at 20/100, with intraocular pressure (IOP) of 29 mmHg. The patient underwent anterior vitrectomy, lens removal, with implantation of a capsular tension ring, and transslceral suture of the inferior haptic of the intraocular lens. The postoperative course was uneventful until the fourth month after surgery. At that time he presented with complains of glare, halos, starburst, and permanent pupil dilation. The patient had an uncorrected visual acuity of 20/25. The patient was functionally disabled by the severe light sensitivity, cosmetically unsatisfied with the permanent mydriasis, and was scheduled for an iris cerclage suture. The postoperative period was uneventful with a best spectacle-corrected visual acuity of 20/20 and an IOP of 15 mmHg. The patient reported being extremely pleased with the absence of photophobia and cosmetic appearance in the right eye.

 

Technique

After surgical preparation, three limbal self-sealing paracentesis incisions were made at the 2, 4 and 9-o'clock positions. The internal aspect of each paracentesis was enlarged to allow better needle manipulation while suturing. A viscoelastic material was then injected into the anterior chamber through the corneal incision. Small vitreous strands were cut with Vanass scissors to avoid unwanted traction of the vitreous. A forceps was introduced through the paracentesis to gently grasp the iris and support it while weaving one end of a double-armed 10-0 polypropylene suture on a curved needle through the iris at the pupillary margin between the first paracentesis opening and the adjacent second paracentesis opening. The suture was aimed to pass approximately 0.5 to 1.0 mm peripheral to the margin taking multiple small bites. The tip of the viscoelastic cannula was then introduced through the opposite side of the first paracentesis as a guide. The tips of the cannula and the suture needle were aligned so the cannula captured the polypropylene suture needle. The cannula holding the 10-0 suture was gently retracted from the paracentesis leaving the first quadrant done. After the initial pass the 10-0 polypropylene suture was reintroduced, taking care not to capture corneal tissue. The process of entering through paracentesis openings, weaving through the iris, and exiting through the next paracentesis was done until the entire pupillary circumference was engaged. The final needle exited the eye through the first paracentesis. After the suture was passed 360° around the pupil margin, it was pulled and tied with a slip knot. The iris suture was then cut close to the knot, and positioned on the anterior surface of the iris distal to the pupil margin. The pupil was relatively round with a final diameter of approximately 3.0 mm. Through the paracentesis openings the viscoelastic material was aspirated with an irrigation/aspiration unit, and stromal hydration was used to seal any leaking paracentesis openings.

Comment

The iris cerclage creates a round pupil with minimal focal stress on the iris. Numerous small bites improve the cosmetic appearance, and avoiding excessive traction on the iris root prevents iridodialysis. However, in areas of iris atrophy longer bites are suggested to prevent the suture from pulling through the atrophic iris stoma. Degradation of the polypropylene suture may be a problem long term causing some surgeons to recommend multiple interrupted sutures.

The use of a slip knot facilitates the adjustment of the tension of the desired pupil diameter. The sutured pupil would be nonreactive, therefore it is important to leave an adequate pupil size for future evaluation of the fundus. We would recommend a pupil size of approximately 4.0 to 4.5 mm, larger than the current case. If needed, the suture could be cut during future surgery or possibly lysed with the Argon laser. This would allow visualization in the event of a retinal complication.

We believe the previously described [1,3,4] iris cerclage suture technique with running suture is a way to surgical repair diffuse iris sphincter damage in a symptomatic patient creating a pupil that is precisely sized and rather round.

Conflict of Interest Statement

Supported in part by NIH/NEI EY-014793 and an unrestricted grant to MUSC-SEI from Research to Prevent Blindness, New York, NY, USA.

None of the authors have a proprietary interest in any product mentioned.


Acknowledgement

The authors thank James P. Byrnes, Storm Eye Institute, MUSC, for his expert contribution in the video editing of this case.


References

    • Ogawa GS. The iris cerclage suture for permanent mydriasis: A running suture technique. Ophthalmic Surg Lasers 1998;29:1001-1009.
    • Osher R. Traumatic mydriasis. Video J Cataract Refract Surg 1995;11:(2).
    • Bucher P. Iris cerclage. Audiovisual J Cataract Implant Surg 1991;7:(3).
    • Steinert RF. Reconstructing the iris. Presented at the Symposium on Cataract, IOL and Refractive Surgery. April 18-22, 1998. San Diego, California.