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Intraocular suturing
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 Iris trauma sustained during cataract surgery. |
An ophthalmologist friend e-mailed me last week asking for advice in suturing an IOL to the back of the iris. When we see experts at national meetings showing videos of this technique, it always looks so easy. Certainly, the concepts are relatively simple, but it's a technique that requires considerable practice and time to master. In the Los Angeles area, I get referred these patients on a frequent basis, so I'll present a case that I recently saw.
This patient sustained iris trauma and a ruptured posterior capsule during cataract surgery. A negative spherical aberration IOL was placed in the ciliary sulcus, oriented at 2 and 8 o'clock, but it has since nasally decentered. The patient had a history of refractive surgery and has ended up with a refraction of +3.00 –1.25 x 110, giving a best corrected vision of 20/30. The patient notes considerable difficulty with the glare and poor image quality. The posterior segment appears normal with no evidence of macular edema.
The issues here are suture fixation of the IOL and then suture closure of the iris defect. In addition, the power of the IOL is too low for the eye, resulting in a postoperative hyperopic surprise. We can do an IOL exchange with the new IOL oriented in a more stable meridian and then sutured to the posterior surface of the iris if needed. The iris defect can then be sutured using a Siepser or McCannel knot technique. Intraocular micro-instrumentation is available from multiple companies and typically includes forceps, tiers and scissors - all of which can fit through a 23- or 25-gauge paracentesis incision. Keeping the anterior chamber filled with viscoelastic will prevent collapse.
In this case, I think that replacing the negative spherical aberration IOL, which may induce coma upon decentration, with a zero spherical aberration IOL, which is relatively immune to decentration, would be helpful. In addition, the IOL power will be adjusted to aim for a postoperative refraction close to plano.
What pearls do you have to offer in this challenging case?
See Dr. Devgan share more expert insight live at OSN New York 2010, to be held November 19-21, 2010 at the Sheraton New York Hotel & Towers. Learn more at OSNNY.com.