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What pupilloplasty technique do you use most often?
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Determine extent of damage
The iris is a delicate, even finicky, tissue that has an important role in our vision. Damage to it can sometimes be surgically repaired using pupilloplasty techniques. My approach is to determine the extent of the damage, measured typically in clock hours as well as the residual sphincter function. The iris should be examined at the slit lamp with both direct illumination and retroillumination. Presence of transillumination defects can alert the ophthalmologist to the extent of loss of the posterior iris pigment in eyes in which the anterior iris stroma is still intact.
The goal of pupilloplasty is to restore both form and function and to hopefully provide an acceptable cosmetic result. Restoring a pupil can improve image quality and decrease glare symptoms and light sensitivity. If the patient has just 1 or 2 clock hours of iris loss or damage, 10-0 Prolene sutures can be used to reapproximate the tissue. Care should be taken to avoid suturing at the pupil margin and to ensure a reasonable level of dilation for future retinal examinations.
If the iris damage is more extensive, then a prosthetic iris implant may be a better choice, but these are limited to just a few sites in the United States. Finally, keep in mind that cosmetic contact lenses can also play a role in symptomatic relief for patients with iris damage. Patients should understand the limitation of surgery and accept that their condition can be made better, but not restored to perfect.
Uday Devgan, MD, is Healio.com/OSN Section Editor. Disclosure: Devgan reports no relevant financial disclosures.
Single-pass four-throw technique
The most commonly employed technique by me for a pupilloplasty procedure is the single-pass four-throw (SFT) technique, wherein after the initial pass of suture through both the leaflets of iris tissue that is to be apposed, a loop is withdrawn and the suture end is passed four times through this loop. The suture ends from both sides are then pulled, and the loop slips inside and apposes the iris tissue.
There are many advantages with SFT. As only a single pass is needed, it is not essential for the surgeon to pass the needle again from the anterior chamber. This decreases the intraoperative manipulations. It is also preferred in endothelial keratoplasty procedures, as the bulk of the knot is absent in the anterior chamber. So, there are fewer chances of the suture rubbing against the endothelium of the donor graft.
Currently, we also use this for cases with angle-closure glaucoma with very good results. The procedure pulls the iris from the peripheral area and prevents overcrowding of the angle. SFT has also been shown to control IOP and break the peripheral anterior synechiae, especially in cases with plateau iris syndrome and Chandler’s syndrome in which it was also coupled with pre-Descemet’s endothelial keratoplasty.
We have noticed that when SFT is performed, the area of the iris that is not touched by the pupilloplasty procedure dilates under the effect of topical mydriatics. This allows better fundus examination and is a boon to the retina surgeon who might need to dilate the pupil in the future for any retinal pathology after SFT surgery. Other potential indications include cases in which the angle remains appositionally closed despite a patent iridotomy and in cases that are unresponsive to medical management of angle-closure glaucoma.
Amar Agarwal, MS, FRCS, FRCOphth, is chairman of Dr. Agarwal’s Eye Hospital. Disclosure: Agarwal reports no relevant financial disclosures.