Innovative Iris Repair

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Esmond Norris
5 years ago
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Disclosure Statement I have no financial relationships with commercial entities that produce health-care related products and/or services pertinent to this presentation.

1 UNC Eye Symposium April 2, 2016 Chapel Hill, NC Innovative Iris Repair D Mark A. Terry, MD Director, Corneal Services Devers Eye Institute Scientific Director Lions VisionGift Research Lab Portland, Oregon, U.S.A. Disclosure Statement I have no financial relationships with commercial entities that produce health-care related products and/or services pertinent to this presentation. Abnormal Pupils: Etiology Iris Defects Treatment Options Acquired Traumatic (blunt and penetrating) Ischemic mydriasis (pupillary block sequellae) Iridodialysis Post surgical ICE syndrome Congenital Aniridia Iris Coloboma Albinism Occlusive colored contact lenses Corneal tattoo /Iridoplasty Anterior segment reconstruction Artificial Iris-Lens diaphragm Prosthetic Irides Benefit: skills not difficult to acquire instruments readily available Limitations not all iris defects amenable to surgical repair can cause iris tear may not be the ideal cosmetic outcome defects may remain Ideal for the smaller, superior defect! traumatic cataract & mydriasis Standard Phaco Avoid cycloplegics Single McCannel suture of 10-0 prolene: Avoid tying stroma to iris in the knot! 1

3/20/16 Modified McCannel Suture using Siepser Slip Knot Technique S 10-0

avoid S passed through a single cycloplegics or epi paracentesis at

Multiple McCannel sutures of 10-0 prolene: Start with middle suture, then

paracentesis site using Siepser slip knot technique S Tighten slowly to

suture S Best for traumatic or ischemic S circular mydriasis 72 y/o man

Siepser, MD, The Closed-Chamber Slipping Suture Technique for Iris

S Iridodialysis S Even 10 mm pupils with bunched up iris in angle can be

passed in and S 45 y/o woman had 1 year traumatic mydriasis out of

determine exact size of new pupil with only one knot S Iridodialysis S

with a 30 guage needle and then insert 10-0 prolene into needle tip

needle without the suture back into the anterior chamber S Cataract S

2 3/20/16 Modified McCannel Suture using Siepser Slip Knot Technique S 10-0 prolene on CIF-4 curved needle For Very large pupils: S Standard Phaco: avoid S passed through a single cycloplegics or epi paracentesis at limbus, through iris defect, out of the cornea at opposite limbus S Multiple McCannel sutures of 10-0 prolene: Start with middle suture, then pupillary suture, then peripheral suture S tied through a single paracentesis site using Siepser slip knot technique S Tighten slowly to avoid tearing or root dialysis Pupiloplasty with purse-string prolene suture S Best for traumatic or ischemic S circular mydriasis 72 y/o man with blunt trauma at age 12 who had 9.0 mm pupil for 60 years (S. Siepser, MD, The Closed-Chamber Slipping Suture Technique for Iris Repair, EyeWorld, July 1997, page 3). S Iridodialysis S Even 10 mm pupils with bunched up iris in angle can be treated S Cataract S Requires 4 paracentesis sites S CIF 10-0 prolene passed in and S 45 y/o woman had 1 year traumatic mydriasis out of paracentesis sites with 8 total bites of pupillary margin S Easily determine exact size of new pupil with only one knot S Iridodialysis S Zonular Dehiscence Iris Dialysis Repair: Closed Repair Engage iris edge with a 30 guage needle and then insert 10-0 prolene into needle tip Re-Engage iris with needle carrying suture into ant ch and out Withdraw needle without the suture back into the anterior chamber S Cataract S Zonular Dehiscence Tips: No dilating drops preop Repair iris root first, then intraocular phenylephrine, then phaco Remove suture from needle Exit under a small scleral flap 2

3 Iris Dialysis Repair: Re-engage iris edge with needle, exit needle through sclera Withdraw needle into Ant Ch with suture, Re-engage original iris edge, and Exit through original scleral flap bed Completed procedure: With only one buried knot Iridodialysis Cataract Zonular Dehiscence Re-insert suture into needle tip Pull suture end from needle and tie Close scleral flap over knot Iridodialysis Repair: Anterior Segment Reconstruction with Iris Repair repair of iris dialysis 33 y/o man with Lye burns to face and both eyes traumatic cataract extraction Further pupilloplasty to reduce pupil size further can be done if desired Anterior Segment Reconstruction Technique Pre-op: Corneal Scar, PAS, Cataract, Vitreous, etc After trephination: Excise cornea without tearing PAS Anterior Segment Reconstruction Technique Strip surface iris fibrosis membranes Purse-string suture of iris with prolene suture 1 Perform vitrectomy, lens removal Scar excision with open sky Dissect PAS with Sponge tips 2 5 Completion of circular artificial iris sphincter

Anterior Segment Reconstruction with Iris Repair

traumatic/acquired glare, photophobia, poor depth

etc. Post-op Ant Chamber Reconstruction With Iris

Prosthetics Morcher IOL or Iris Implants Morcher

Optics Implants Currently Requires Special

> 11 mm incision ciliary sulcus if capsular

reconstruction implants requires intact capsule

larger incision except for the newer models only

Ophthec Implants Ophthec model 311 IRI Ophtec BV

4 Anterior Segment Reconstruction with Iris Repair Large Iris Defects or Aniridia congenital or traumatic/acquired glare, photophobia, poor depth of field, poor functional vision, poor cosmesis, etc. Post-op Ant Chamber Reconstruction With Iris Repair When not enough tissue left to repair: Iris Prosthetics Morcher IOL or Iris Implants Morcher segments and black out IOLs Ophthec Implants Human Optics Implants Currently Requires Special Compassionate Use Exemption by the FDA to be used in the U.S. aniridic IOL IOL with an integrated iris diaphragm > 11 mm incision ciliary sulcus if capsular support or transclerally sutured Iris reconstruction implants requires intact capsule and large rhexis black PMMA --- brittle needs larger incision except for the newer models only in black color Types of Morcher endocapsular IRIs. Ophthec Implants Ophthec model 311 IRI Ophtec BV (Groningen, The Netherlands) 9.5 mm incision 9.0 mm diameter, 4.0 mm clear optic diameter brown, blue, green aphakic, or pseudophakic to sulcus or sutured While effective at blocking glare, Cosmetic result is less than ideal 4

3/20/16 Human Optics Implants Summary S Pupillary

debilitating glare S Preoperative evaluation is

extent and location of iris tissue loss, patient

or sewn to ciliary sulcus concomitant pathology,

Conservative measures should be considered first

Is the iris defect amenable to pupilloplasty?

5 3/20/16 Human Optics Implants Summary S Pupillary abnormalities and iris defects can cause debilitating glare S Preoperative evaluation is critical Excellent Cosmetic Results S evaluate extent and location of iris tissue loss, patient expectation, Relative easily placed in capsular bag or sewn to ciliary sulcus concomitant pathology, and need for other surgical intervention S Conservative measures should be considered first Downsides: expensive ($5,000+) not FDA approved S Is the iris defect amenable to pupilloplasty? If so, this is the most desirable option for cost and cosmesis. S Advances in iris prosthesis give new hope for our trauma patients All photos courtesy of Sam Masket, M.D. NICHOLAS CHARLIE CINDY 5

Samuel Masket MD Advanced Vision Care Clinical Professor - UCLA Los Angeles

Surgery for defects of the IRIS Samuel Masket MD Advanced Vision Care Clinical Professor - UCLA Los Angeles Iris Defects Loss of Iris Tissue or function can have devastating effects on quality of vision,