The pupil may contract or dilate depending on the amount of light entering the eye. Jing W, Guanlu L, Qianyin Z, et al. The pupil is an aperture or an opening in the center of the iris of the eye. Then, make two incisions on either side in the limbus along the axis of the iris defect. The iris cerclage suture for permanent mydriasis: a running suture technique. 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. Corresponding author: Ticiana De Francesco, MD, 499 Rua Baro de Aracati, Fortaleza CE, Brazil, 60115-080. More sophisticated techniques are required to address pupil centration, contour, and aperture size to optimize outcomes of pupil reconstruction beyond just iris defect closure. First author:Ticiana De Francesco, MDClnica De Olhos De Francesco, Fortaleza, Ceara, Brazil. Application of pinhole optics by performing PPP leads to significant improvement in image quality and helps to optimize visual potential in post-RK cases. Tie the suture securely and repeat the procedure until the normal pupil size is achieved. [3]. [13] First author:Ticiana De Francesco, MDClnica De Olhos De Francesco, Fortaleza, Ceara, Brazil. Techniques to address the shape and size of the pupil include the use of microscissors or a vitreous cutter to cut iris tissue. 1994;26(3):71-72. A hook introduced through the stab incision is used to bring both ends of the suture out of the eye where it is then tied pulling the pupillary edges together to close the defect. 1985;92(5):641-645. Complex cataract surgery, iStent, Pupilloplasty. Shannon Wong - YouTube [11] [12]. 2. The procedure of SFT is repeated in the opposite quadrant, and a minimum of 4-point traction is achieved. Intraocular lens surgery: selection, complications, and complex cases. More. Narang P, Agarwal A, Kumar DA, Agarwal A. Pinhole pupilloplasty: small-aperture optics for higher-order corneal aberrations. Dilated Pupil After Cataract Surgery - Health Hearty The condition of the pupil and retropupillary iris-fixated IOL improved after the reconstruction was complete (B). Lian R, Siepser S, Afshari N. Iris reconstruction suturing techniques. 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. The most pleasing aspects of a pupil are its centration, shape, roundness, and symmetry. 1241: Resident ACIOL and Pupilloplasty - Cataract Coach Several pupilloplasty techniques exist for iris defect closure and iris edge reapposition. It is minimally traumatic with less risk for endothelial and iatrogenic damage compared with using a vitrector or microscissors to remove excess iris tissue. [8], Although pupilloplasty is rarely performed solely for cosmesis, it can be considered, especially in large colobomas in a colored iris and it can provide functional and cosmetic repair.[9]. 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. More sophisticated techniques are required to address pupil centration, contour, and aperture size to optimize outcomes of pupil reconstruction beyond just iris defect closure. After 1 month, pupilloplasty and IOL implantation using an artisan iris-fixated technique were performed. Indications for surgery can be divided into these five main categories: A. Symptomatic iris defects can be considered for surgical intervention, symptoms can range from glare, shadow images and diplopia. 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. No other disclosures were reported. Follow-up examinations were scheduled up to 3 months postoperative to assess the success of the procedure by comparing visual acuity and IOP at baseline and 3 months after the operations. These defects can result in various issues including loss of visual acuity, increased optical aberrations, photophobia, glare, and night vision disturbances. In our practice, we often perform EDP for cases of decentered and corectopic pupils, irregular pupil shape, or small pupillary aperture secondary to traumatic iridodialysis or iris coloboma. This page has been accessed 28,267 times. Xiang W, Zhong X, Chen H, Chen W, Chen W. Pupilloplasty by radiofrequency diathermy. 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 . 2019;2019:1-7. 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. Osher described a modification of the Siepser slip-knot that allowed the knot to become locked, decreasing the chance of suture failure in 2005. The collective use of the Siepser Double Sliding Knot and Pupilloplasty technique offers an excellent recovery of the physiologic function and cosmesis post-operatively in patient with pre-existing traumatic iris dysfunctions. Please try after some time. This patient sustained blunt trauma to his eye and then developed chronic mydriasis and a cataract with significant zonular loss. 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. More sophisticated techniques are required to address pupil centration, contour, and aperture size to optimize outcomes of pupil reconstruction beyond just iris defect closure. The pupillary stretch is performed every 2-clock hours around the entire pupillary margin. Some error has occurred while processing your request. (c) Knot cut with microscissors. 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. doi: 10.1097/j.jcrs.0000000000000718. 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. 1. Furthermore, coagulation may induce some inflammation, but this can be well controlled with early postoperative topical steroids. Iris microendodiathermy is a simple technique that is minimally traumatic, titratable, and controlled, avoids excessive tissue manipulation, and is able to create a round cosmetically pleasing pupil. 2018 Jan;66(1):120. This is controlled by the level of energy applied, duration of application, and, most significantly, distance from the pupil margin. Pupil cerclage technique re-establishes the pupil with a precise regulation of the pupil size without distortion of its natural round shape. If the diathermy probe is applied at a distance closer to the pupil margin, more effect is achieved. In the contralateral side (the upright side of the iris), procedures B and C are repeated until proper pupil size is achieved (E). 2023 Bryn Mawr Communications, LLC. Invest Ophthalmol Vis Sci. Disclosures: I.I.K. 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. In addition, the self-consciousness around having a distorted pupil can impact the patient psychologically with loss of confidence and self-esteem. All surgical procedures were performed by the same surgeon (S.S.). to maintaining your privacy and will not share your personal information without Yao Y, Jhanji V. Simplified pupilloplasty technique through a corneal paracentesis to manage small iris coloboma or traumatic iris defect. 2019;35(3):207-208. Endothermal pupilloplasty to optimize pupil centration, size - LWW J Refract Surg 2012;28:281283, 5. A vitrector or microscissors can cut and attempt to reshape the pupil; however, both consist of cutting or removing tissue and typically do not leave a smooth and circular pupillary margin. Combined Pupilloplasty and Iris-Fixated IOL Implantation In all three patients, visual acuity showed significant improvement 3 months postoperative (Table). 10. Aaopt.org. [2] Reconstruction of the iris and pupil provides an opportunity to address the visual, functional, and cosmetic issues for patients. If IOP drops, the globe must be filled with balanced salt solution immediately. European Journal of Ophthalmology. In addition, it is best to apply cautery away from the suture knot as it may result in a broken suture; however, this is uncommon. Solomon R, Barsam A, Voldman A, Jack H, Bhogal M, Perry H, Donnenfeld E. Argon laser iridoplasty to improve visual function following multifocal intraocular lens implantation. 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. It is through the pupil that the light enters the retina. The re-creation of an optimally sized and centered pupil is often challenging because of missing iris, asymmetrical iris damage, or variable tension around the pupil. For more information, please refer to our Privacy Policy. 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. Eur J Ophthalmol. 2006;32(11):1913-1916. Retina 2015;35:26472649, 3. This technique provides exquisite control to achieve a cosmetically pleasing pupil and iris repair, thereby improving the patient's quality of life. [15] [16]. The 26-guage needle is pulled along with the suture, then securely tied (D). Pupil Size and Cataract Surgery. In long-term postoperative follow-up, cautery application to the iris rarely regressed. Stopa M, Rakowicz P. Sutureless iris repair: cauterization technique. In our practice, we often perform EDP for cases of decentered and corectopic pupils, irregular pupil shape, or small pupillary aperture secondary to traumatic iridodialysis or iris coloboma. There are several advantages that EDP offers over current pupil reshaping techniques. 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. A similar nonsurgical technique for adjusting pupil location and size is argon laser pupilloplasty.4,5 This technique has been used postoperatively in eyes with a decentered multifocal intraocular lens to improve visual function.4 It may also be used in combination with argon laser peripheral iridoplasty to relieve pupil block.5 Although postoperative laser photocoagulation is an option, we do not find it as controlled as intraoperative adjustments. This allows enlargement, reshaping, or repositioning of the pupil and large laser iridotomies with minimal burn energies and a very high percentage of success. Typically, this complication occurs because of excessive tissue manipulation or overstretching. Visual outcomes and complications of posterior iris-claw intraocular lens implantation in aphakic postvitrectomized eyes. 2018;66(1):120. Pupilloplasty - Webvision - University of Utah Canadian Journal of Ophthalmology. It minimizes instrumentation and tissue manipulation in the anterior chamber to achieve excellent functional, visual, and cosmetic outcomes and can be readily accessible in most operating rooms.WHAT WAS KNOWN Otherwise, an iatrogenic iris tear may result. 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. We used the single-pass four-throw (SFT) approach with a secondary iris-fixated IOL implantation. To log in, click the teal "Login" button in the upper right-hand corner of this page. EDP is a straight forward and minimally traumatic method to optimize pupilloplasty outcomes by improving pupil centration, size, and contour. After the iris sutures are placed, we use iris cautery to refine the pupil centration and size. More sophisticated techniques are required to address pupil centration, contour, and aperture size to optimize outcomes of pupil reconstruction beyond just iris defect closure. SFT PUPILLOPLASTY. Some minimal iris discoloration is expected, but this is often very subtle and visible only under the microscope (Figure 3). Ophthalmic Surg Lasers. Pupilloplasty. However, in our 10 years of experience, we have noted minimal regression in treated patients, although some depigmentation is expected (Figure 4). January/February 2022 | Global Perspectives, Repairing surgically aphakic patients who have had a previous vitrectomy is complicated due to insufficient capsular support and/or major alterations in the anatomy of the anterior chamber, especially in the presence of iris defects.1,2, A significant cause of iris defects is pupil atonia, one of the most common complications of anterior segment surgery. Dr. Stephen Wilmarth M.D. The artisan IOL is inserted, and the lens is properly enclavated in the anterior chamber (F). 2. A well-centered, round, and reasonably sized pupil is of critical importance to the cosmesis of the eye, which should not be ignored and recognized as an important outcome of pupil repairs.
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