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2. This technique consists of using a 23-gauge endodiathermy straight blunt tip bipolar cautery (Dutch Ophthalmic Research Center) (Figure 1) to apply light cautery to the midiris stroma, which gently stretches the pupil in the meridian to which cautery was applied (Video 1 available at https://links.lww.com/JRS/A402). Yao Y, Jhanji V. Simplified pupilloplasty technique through a corneal paracentesis to manage small iris coloboma or traumatic iris defect. Unlike preceding methods, the Siepser Double Sliding Knot technique allows sutures to be tied within the eye without impairing delicate uveal tissue thus keeping a well-maintained anterior chamber during the process. 9. More sophisticated techniques are required to address pupil centration, contour, and aperture size to optimize outcomes of pupil reconstruction beyond just iris defect closure. Iris defects and distorted pupils are commonly managed with iris suturing techniques that aim to close the defect and/or reform the physiological pupil. Journal of Cataract & Refractive Surgery: December 2021 - Volume 47 - Issue 12 - p e80-e83. Zhou W, Zhao F, Shi D, Qadri M, Jiang L, Ma L. Argon laser peripheral iridoplasty and argon laser pupilloplasty: alternative management for medically unresponsive acute primary angle closure. 1 Not only fixed and dilated pupils but also irregular pupils due to complete iridectomy are bothersome, particularly in . Indian journal of ophthalmology. [1] In 1985, Alpar modified the McCannel technique by using Healon ( 1% sodium hyaluronate) in cat eyes with improved corneal protection, less change in pachymetry, and less decrease in endothelial cell counts. Zarranz-Ventura J, OConnell E, Haynes RJ. What are the advantages of RLE? This happens when the back of the lens capsule the part of the lens that wasn't . Visual outcomes and complications of posterior iris-claw intraocular lens implantation in aphakic postvitrectomized eyes. Arundhati A, Hui Jun B, Janardhan P, Tan D. Iris Reconstruction in Penetrating KeratoplastySurgical Techniques and a Case-control Study to Evaluate Effect on Graft Survival. Course Instructor: Hazem M. Yassin, MD. The use of Healon in McCannel suturing procedures. The authors would like to express their gratitude to Erik Hookom for his help in proofreading the article. Cionni R, Karatza E, Osher R, Shah M. Surgical technique for congenital iris coloboma repair. Please try again soon. A senior resident booked the surgery to remove the cataract, provide more capsular support, insert the IOL, and then perform the pupilloplasty. your express consent. J Refract Surg. Typically, this complication occurs because of excessive tissue manipulation or overstretching. (a) Suture end is passed through the loop and 4 throws are taken. The goal of this technique is to create and maintain an appropriate pupil size to alleviate symptoms while still permitting adequate light during scotopic conditions and allowing for an adequate posterior segment examination. The McCannel technique involves passing a 10-0 polypropylene suture through two paracenteses, which had been created perpendicular to the edge of an iris defect. Based on our small and limited retrospective study, and under unusual circumstances, urgent tube shunt implantation through the ciliary sulcus may be considered in phakic eyes with severely uncontrolled IOP . Narang P, Agarwal A. Single-pass four-throw pupilloplasty knot mechanics. A bipolar endodiathermy cautery is applied to the iris stroma to induce tissue contraction and to gently pull the pupil in the meridian to which probe is applied. You may be trying to access this site from a secured browser on the server. The functional and cosmetic outcome of iris defect repair is often not ideal, resulting in intolerable glare, photophobia, visual distortion, and poor cosmesis. Before pupilloplasty in case number two, the patient has a pathologic large pupil in an aphakic-vitrectomized eye (A). The degree of control is excellent, and the amount of tissue contraction will dictate how much the pupil is enlarged. The pupil plays an important role in ocular function, vision, light transmission, and cosmesis. 2017;52(2):155-160. From our experience, the degree of stromal contraction is greater in darker-colored than lighter-colored irides because of greater thermal absorption with greater pigmentation but can be effective in both. when used in ACG , iris traction would be proportional to the degree of angle closure. Wolters Kluwer Health Financial disclosure: None, Medical Doctor, International SOS, Jakarta, Indonesia 2020;31(1):43-49. In all three patients, visual acuity showed significant improvement 3 months postoperative (Table). The suture ends are then cut with the microscissors. J Cataract Refract Surg 2005;31:1098-100. [15] [16]. After the iris sutures are placed, we use iris cautery to refine the pupil centration and size. This allows enlargement, reshaping, or repositioning of the pupil and large laser iridotomies with minimal burn energies and a very high percentage of success. The functional and cosmetic outcome of iris defect repair is often not ideal, resulting in intolerable glare, photophobia, visual distortion, and poor cosmesis. Radial keratotomy (RK) was the most commonly performed refractive surgery in 1980s that involved . Indian Journal of Ophthalmology. 2. EDP could possibly avoid these complications, introducing minimal instrumentation into the anterior chamber, thereby reducing trauma, potential endothelial damage, and risk for iatrogenic damage during surgery. There is also a risk for further trauma and bleeding with cutting techniques. American Journal of Ophthalmology. Aaopt.org. The pupil is the aperture through which light passes into the eye and is created by the circular ring of thin muscles known as the iris. Cases of iris defect in aphakic-vitrectomized eyes present ophthalmologists with a whole new set of challenges, considering even typical treatments are complex and difficult. Although pupil defects are traditionally challenging to refine to adequate size, shape, and centration during suture repair, this study presents a titratable technique to restore a normal pupil size and contour without excessive manipulation, bleeding, or instrumentation. To the authors' knowledge, this is the first description of EDP. This is controlled by the level of energy applied, duration of application, and, most significantly, distance from the pupil margin. If the pupil aperture is too large or an iris gap remains after cautery, the pupil shape may be refined by returning to the suturing step and repeating the process to achieve a round and central pupil. . Narang P, Holladay J, Agarwal A, Jaganathasamy N, Kumar DA, Sivagnanam S. Application of Purkinje images for pinhole pupilloplasty and relevance to chord length mu. For a decentered pupil, diathermy is applied in a sectoral fashion to cause contraction of the iris tissue and gently pull the pupil in the direction to which cautery was applied, aiming for recentration (Figure 2). Endodiathermal pupilloplasty a technique to optimize pupil centration, size, and contour. Transactions of the ophthalmological societies of the United Kingdom. These images are from a pupilloplasty made with a 10.0 prolene suture. Complex cataract surgery, iStent, Pupilloplasty. In cases of a small pupil, cautery can be applied circumferentially to enlarge the pupillary margin. The 10-0 needle is then passed through the distal iris tissue, and the tip of the 10-0 needle is then docked into the barrel of the 26-gauge needle introduced from the paracentesis incision from the opposite side. Conversely, if it is used farther away, less effect is achieved. Vitreoretinal Surgeon, Dr. Sardjito General Hospital; Ophthalmology Department, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta; Dr. S. Hardjolukito Air Force Hospital, Yogyakarta Indonesia Corresponding author: Ticiana De Francesco, MD, 499 Rua Baro de Aracati, Fortaleza CE, Brazil, 60115-080. Application of pinhole optics by performing PPP leads to significant improvement in image quality and helps to optimize visual potential in post-RK cases. Educational Objective Improve management of surgical complications Course Description Video based course, highlighting important aspects of papilloplasty and iris reconstruction. 1998;24(11):1429-1431. This technique is regarded as the simplest form of surgical pupillplasty, with short learning curve. We did not observe intraoperative bleeding for any eyes in which this technique was used. We congratulate Sridhar and Raber on their well-described method of pupilloplasty. In one survey, 60% of responding cataract and refractive surgeons encountered at least one case of pupil atonia after cataract surgery in the last 5 years.3,4 Light sensitivity is common in patients with an atonic pupil secondary to trauma; thus, these cases require a challenging surgical technique for repairing the defects.5,6, Pupilloplasty, commonly used to repair damage associated with iris dysfunction, recreates the proper size of the pupil while maintaining the structural integrity of the iris tissue. Refractive lens exchange (RLE) is a minor surgical procedure in which your natural (clear) lens is exchanged for an artificial lens with the correct power for your eye. There is also a risk for further trauma and bleeding with cutting techniques. Dr. Agarwal fully describes the technique in this paper from the European Journal of Ophthalmology . 8. In long-term postoperative follow-up, cautery application to the iris rarely regressed. This patient sustained a ruptured globe injury . There are several advantages that EDP offers over current pupil reshaping techniques. This technique was especially useful in cases of multifocal intraocular lenses. This activity is supported by an independent medical education grant from Genentech, a member of the Roche Group. Narang P, Agarwal A, Kumar D. Single-pass four-throw pupilloplasty for angle-closure glaucoma. For a decentered pupil, diathermy is applied in a sectoral fashion to cause contraction of the iris tissue and gently pull the pupil in the direction to which cautery was applied, aiming for recentration (Figure 2). Cataract 2021 Instructional Course aniridia iris reconstruction iris repair iris suture artificial iris 2021 ASCRS Annual Meeting Instructional Courses This 1.5 hour Instructional Course was recorded at the 2021 ASCRS Annual Meeting in Las Vegas, Nevada, held on July 24-27, 2021. Endothermal pupilloplasty (EDP) does not remove or cut iris tissue, elicits minimal inflammation, has a short learning curve, and is titratable and controlled. The artisan IOL is inserted, and the lens is properly enclavated in the anterior chamber (F). Free; PAP; Metrics Abstract. If the diathermy probe is applied at a distance closer to the pupil margin, more effect is achieved. All rights reserved, JRS_2021_06_15_FIGUEIREDO_21-137_SDC1.mp4; [Video] (86.46 MB), Endothermal pupilloplasty to optimize pupil centration, size, and contour, Articles in PubMed by Ticiana De Francesco, MD, Articles in Google Scholar by Ticiana De Francesco, MD, Other articles in this journal by Ticiana De Francesco, MD, Privacy Policy (Updated December 15, 2022). However, in our 10 years of experience, we have noted minimal regression in treated patients, although some depigmentation is expected (Figure 4). Pupilloplasty Surgery in Albany NY Patient Portal Patient Resources Contact 9 Vista Boulevard, #100 Slingerlands, NY 12159 518.475.1515 Request Appointment 518.475.1515 Email Us Questions? Cataract Surgery: My Most Difficult Case. Alpar JJ. Please try after some time. We did not observe intraoperative bleeding for any eyes in which this technique was used. In addition, the self-consciousness around having a distorted pupil can impact the patient psychologically with loss of confidence and self-esteem. Preoperative documentation of contralateral pupil size is helpful as a reference. We chose the SFT technique because it provides some advantages over other techniques, including reduced surgical manipulation, fast surgical time, and dissemination of the pigment in previously compromised eyes.7,8 It also offers faster rehabilitation and reduced inflammation in postoperative settings.9 Recently, interest in the SFT technique has grown because it can significantly reduce photophobia and glare.10,11 All procedures were performed under local anesthesia (topical pantocaine and intracameral lidocaine 2%) under monitored care. Xiang W, Zhong X, Chen H, Chen W, Chen W. Pupilloplasty by radiofrequency diathermy. Journal of Cataract & Refractive Surgery47(12):e80-e83, December 2021. This page was last edited on February 27, 2023, at 12:00. Many of these symptoms can cause severe disability and significantly impact quality of life. This results in an improved self-esteem and quality of life for the patient. Weissbart SB, Ayres BD. To prevent post-operative complications as in PKP (penetrating keratoplasty), 4. J Ophthalmol 2019;2019:17. may email you for journal alerts and information, but is committed Then, two incisions are made on both sides of limbus, along the axis of iris defect (B). The pupillary margin is grasped with an end-opening forceps and pulled toward the center of the pupil. After the iris sutures are placed, we use iris cautery to refine the pupil centration and size. The cosmetic result is particularly notable with this technique in the ability to produce an exquisitely round, centered, and symmetrical pupil in our experience. A full thickness stab incision is then created between the paracenteses through the peripheral cornea. Several pupilloplasty techniques exist for iris defect closure and iris edge reapposition. For more information, please refer to our Privacy Policy. 1555: Pupilloplasty made easy Uday Devgan MD August 9, 2022 guest surgeons, iris suturing Previous Next The iris can be sutured, typically using 10-0 polypropylene, to help restore the pupil anatomy in cases of iris trauma. IC-115 Dropfree Cataract Surgery: Take Control of Perioperative Care. Ocular Surgery News | Pupilloplasty is performed to alter or change the shape of a pupil that does not conform to normal pupillary dimensions, and there are several techniques surgeons can use. From the Clnica De Olhos De Francesco, Fortaleza, Ceara, Brazil (De Francesco), the Hospital De Olhos Leiria De Andrade, Fortaleza, Ceara, Brazil (De Francesco), the Escola Cearense de Oftalmologia, Fortaleza, Ceara, Brazil (De Francesco), the Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada (Ma, Ahmed), and the Department of Ophthalmology and Visual SciencesUniversity of Utah, Salt Lake City, Utah (Ahmed). Management of aniridia and iris defects: an update on iris prosthesis options. The pupillary stretch is performed every 2-clock hours around the entire pupillary margin. This iris damage can be from accidental trauma or from iatrogenic causes, like the case shown here. If the diathermy probe is applied at a distance closer to the pupil margin, more effect is achieved. The pinhole effect blocks distorted and unfocused light rays and isolates more focused central and paracentral rays through the central aperture, thereby reducing aberrations of the optical system as a whole and it inceases the depth of focus enhancing visual acuity and its image quality both for near and far. De Francesco, Ticiana MD; Ma, Jingyi BMSc; Ahmed, Iqbal Ike K. MD, FRCSC. 2019;45(6):745-751. When cataract or intraocular lens surgery is performed in patients with traumatic pupil dilation and iridodialysis, the optic edges of the implanted lens are often exposed, regardless if the lens is within the bag or fixed by sutures, causing the patients to feel intolerable halo or inability to focus on objects after surgery. If IOP drops, the globe must be filled with balanced salt solution immediately. Figure 3. Journal of Cataract & Refractive Surgery. Pupilloplasties are designed to reconstruct the shape of the pupil, typically after traumatic damage or other surgical . Limitations of this technique include the unknown long-term stability of cautery-induced iris contraction. The Current Procedural Terminology (CPT ) code 66682 as maintained by American Medical Association, is a medical procedural code under the range - Repair Procedures on the Iris, Ciliary Body of the Eye. 1st ed. Stopa and Rakowicz described a sutureless approach to the reapposition of iris tissue edges by using iris cautery instead of suturing to achieve a connection in cases of sectoral iris defects, traumatic mydriasis, and iridodialysis.2 Xiang et al. 2019;45(6):745-751. IC-318 Best Practices for IOL Power Selection in 2021. Furthermore, coagulation may induce some inflammation, but this can be well controlled with early postoperative topical steroids. 1985;92(5):641-645. 2017;58(9):3530. Coagulation is used in a continuous linear fashion with zero% to 40% power and can be attached to a phacoemulsification machine. When operating on a thin and atrophic iris, extra care should be taken to apply very light cautery as iris contraction induced by endodiathermy may result in new iris defects. The iris cerclage suture for permanent mydriasis: a running suture technique. Typically, this complication occurs because of excessive tissue manipulation or overstretching. EDP could possibly avoid these complications, introducing minimal instrumentation into the anterior chamber, thereby reducing trauma, potential endothelial damage, and risk for iatrogenic damage during surgery. The first step in the pupilloplasty is to make a small incision in the cornea and fill the anterior chamber with lidocaine, carbachol, and viscoelastic materials. 1994;26(3):71-72. Photograph of an eye that underwent pupilloplasty and EDP 10 years ago, showing minimal regression of the EDP effect. Curr Opin Ophthalmol 2016;27:244249, 2. From the Clnica De Olhos De Francesco, Fortaleza, Ceara, Brazil (De Francesco), the Hospital De Olhos Leiria De Andrade, Fortaleza, Ceara, Brazil (De Francesco), the Escola Cearense de Oftalmologia, Fortaleza, Ceara, Brazil (De Francesco), the Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada (Ma, Ahmed), and the Department of Ophthalmology and Visual SciencesUniversity of Utah, Salt Lake City, Utah (Ahmed). Our clinical experience using this technique has yielded excellent results regarding visual, functional, and cosmetic postoperative outcomes. [3]. SURGICAL STEPS The first step in the pupilloplasty is to make a small incision in the cornea and fill the anterior chamber with lidocaine, carbachol, and viscoelastic materials. After applying cautery, attention should be paid to ensure that iris tissue is free from the cautery tip before removing it from the anterior chamber. This article describes an additional step when performing pupilloplasty to improve the circular contour and position of the pupillary margin. However, there is suboptimal control with this technique and typically leads to irregular pupil margins, removal of tissue, and difficulty achieving optimal pupil centration and roundness. A 23-gauge endodiathermy straight blunt tip bipolar cautery (Dutch Ophthalmic Research Center). (1D) When the suture ends are pulled, the loop slides inside the iris tissue, yie. During pupilloplasty using the SFT technique in case number one of an aphakic-vitrectomized eye, a small incision is introduced to fill the anterior chamber with lidocaine, carbachol, and viscoelastic materials (A). Many of these symptoms can cause severe disability and significantly impact quality of life. Financial disclosure: None, Medical Doctor, Dr. Sardjito General Hospital; Ophthalmology Department, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Cataract surgery successfully restores vision in the majority of people who have the procedure. 1985;104:558-62. J Cataract Refract Surg. Furthermore, a greater effect can be obtained with endodiathermy, which can also be adjusted with additional sutures to refine the iris and pupil appearance. This can be accomplished by direct closure of iris defects and pupil irregularities with sutures or with an iris prosthesis in cases where there is insufficient iris tissue.1 Although challenging, we prefer to primarily repair the iris if sufficient iris tissue exists as this results in the most natural appearance of the eye. First, it is an effective and simple strategy to avoid causing additional trauma to the iris. Some error has occurred while processing your request. Journal of Ophthalmology. In this surgical technique for pupilloplasty, after a single pass of needle through the edges of iris defect along the pupillary margin, the suture end is passed through the loop with 4 throws, creating a helical configuration in modified Siepser slipknot technique that is self-retaining and self-locking. Based on one authors experiences (S.S.), since the vitrectomized globe is at a higher risk of collapsing during the procedure, surgeons must monitor IOP carefully. Frisina R, Parrozzani R, Tozzi L, Pilotto E, Midena E. Pupil cerclage technique for treatment of traumatic mydriasis. To prevent post-operative complications as in PKP (. Indian J Ophthalmol. Osher described a modification of the Siepser slip-knot that allowed the knot to become locked, decreasing the chance of suture failure in 2005. 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The mean preoperative IOP was 17.7 0.58 mm Hg; 3 months after surgery, mean IOP was 16.4 0.58 mm Hg. Some minimal iris discoloration is expected, but this is often very subtle and visible only under the microscope (Figure 3). Lian R, Siepser S, Afshari N. Iris reconstruction suturing techniques.

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