VIDEO: Working with recalcitrant iris and pupillary apertures

Steven B. Siepser, MD, FACS, demonstrates his technique for working with recalcitrant iris and pupillary apertures:

When doing anterior segment reconstruction, getting a pupil properly positioned along the visual axis and cosmetically acceptable is always complex and demanding. Dr. Michael Snyder has said that using a vitrector to nibble at the pupillary margin can enlarge and move the aperture into a more central location. He also advocates using intraocular bipolar cautery to reposition the iris. I routinely use these techniques with recalcitrant irides and pupillary apertures that are not cooperative. In such difficult cases, I have now also adapted the placement of radial Siepser sliding knots to better reposition the pupil. The video best demonstrates this technique.

Using a diamond or 15° blade, place the paracentesis incisions in line with the displaced pupil so that they are oriented in the direction the pupil needs to move. This is opposite of normally placing the paracentesis perpendicular to the defect to aid in closure. Think of where the vector forces need to be applied in placement of the paracentesis for the sliding knot closure technique. Once established, a CI-F4 (Alcon) or the 16 mm 1/4 circle 9-0 Prolene P99062 (Visionary Medical) is passed through the paracentesis. The needle then goes just behind the pupillary rough of the distal side of the ectopic pupil and out. It is then buried into the more peripheral healthy iris before engaging the needle tip into the awaiting 25- or 27-gauge viscoelastic syringe cannula to “back out” the needle through the distal paracentesis. The cinching throw is then introduced from an external “tie” so as to tighten the iris radially and place tension on the pupillary edge to move it into a more desired position. There are now various ways to cinch the external tie sliding to “lock” or secure this knot in the desired position as described by our very creative colleagues Robert Osher, Michael Snyder, Gary Condon, Ike Ahmed and Amar Agarwal. This is a nice variant using sutures in the iris to actually better control the cosmetic and functional position of the pupillary aperture in congenitally and traumatically injured eyes. One must not forget Dr. McCannel who championed the idea that we could actually suture the iris. His technique was to bring the iris to incision sites to tie them. At the time, it was heresy to even think that the iris could be sutured. My technique added the possibility of using sutures in any meridian without displacing the iris into an incision to tie it but sliding an external knot into the eye to close the iris defect indirectly.

Reference:

McCannel MA. Ophthalmic Surg. 1976;7(2):98-103.

Siepser SB. Ann Ophthalmol. 1994;26(3):71-72.

For more information:

Steven B. Siepser, MD, FACS, can be reached at Siepser Laser Eyecare, 860 E. Swedesford Road, Wayne, PA 19087; email: ssiepser@clear-sight.com.

Disclosure: Siepser reports financial disclosures with Eagle Vision, Katena, Escalon Trek and Vision Lock.