methods of iridodialysis repair

1. IRIDODIALYSIS REPAIR
Presenter: Dr ARCHANA
Moderator: Dr SANGEETHA T

2. DEFINITION
• Iridodialysis is a separation of the iris from its attachment to the
ciliary body
• Also known as COREODIALYSIS.
• Most common cause- Ocular Trauma- either blunt or penetrating
trauma
• Iatrogenic (during cataract surgery)

3. PATHOLOPHYSIOLOGY
• Iris root is the thinnest and weakest portion of the iris stroma
• Hence more prone for detachment from the ciliary body after
any traumatic insult having impact at the iris root

4. CLINICAL FEATURES
• Asymptomatic if there is a small superior iridodialysis- covered
by the upper lid
• Temporal and inferio temporal, inferior iridodialysis are
symptomatic.
• Symptoms- Glare, photophobia, monocular diplopia,polycoria
• Signs- ‘D shaped pupil’

5. MANAGEMENT
• Iris incarceration- Paton ( open chamber incarceration
technique)
• Mc cannel’s suture.
• Hang back technique
• Knotless technique
• Sewing machine technique
• Modified Sewing machine technique
• Single suture customised loop technique
• Riveting Technique

6. PRINCIPLES OF IRIS REPAIR
• Instillation of miotic agent: stretches and increases the surface
area.
• When present, Synechiolysis should be the first step in repair.
• If sphincter is involved ,pupillary margin should be reapposed :
establishes a central pupil and creates more taught iris diaphragm.

7. MC CANNEL’S SUTURE
• McCannel suture iridodialysis repair was performed by using
two double-armed sutures and fixating the peripheral iris to the
scleral wall, approximately 1 mm posterior to the limbus
• The double-armed McCannel suture method begins with one
needle entering the anterior chamber through the corneoscleral
limbus inferiorly
• It then pierces the iris base and exits the chamber angle and
sclera

8. • A second needle is utilized in a similar fashion, entering from
the same incision, but rather piercing the iris adjacent to the
previous iris base site
• The suture is then tied over the sclera and buried
• Though it can be modified, typically a 10-0 polypropylene
suture is used
• McCannel repair requires less manipulation than other
methods of iridodialysis repair

9. • One potential complication of the double-armed McCannel
suture technique is erosion of the suture through the
superficial layers of the eye

10. HANG BACK TECHNIQUE
• 3 clock hour iridoliaysis or less
• Instead of repositioning the iris tightly to the sclera, the
detached iris is suspended by a 10-0 polypropylene suture
inside the normal iris insertion.
• A horizontal mattress suture is placed ab interno and tightened
to bring the iris periphery to inside and under the limbus.

11. • This technique provides an excellent functional and cosmetic
result while minimizing occlusion of the trabecular
meshwork.

13. SEWING MACHINE TECHNIQUE(SMT)
• Retrograde threading of 10-0 prolene suture into 26G needle.
• Creation of partial thickness scleral tunnel parallel to and all
along the iris dialysis (2 mm away from the limbus).
• Pupil constriction by pilocarpine injection through a side port
made with 20G MVR blade 180° degree opposite to iris dialysis.

14. • Creation of suture loops all along the dialysis by passing pre
threaded 26G needle with the suture through the root of iris
dialysis and scleral tunnel from inside out.
• Cutting the loops of prolene and tying the adjacent free ends
to each other so that the knots get buried into scleral tunnel.
• Finally, closure of conjunctiva using 10-0 nylon or vicryl or
using bipolar cautery .

15. MODIFIED SEWING MACHINE TECHNIQUE
• The SMT was further modified using 30G 25-mm long dental
needle instead of 26G needle.
• The dental needle with scalpel tip design has better
penetration with minimal trauma to tissue and suture can be
threaded from both sides of the hub.
• After creating suture loops as described earlier, first free end
of the suture is passed through the loops and tied with the
second free end of suture so that only one knot is sufficient for
entire iris dialysis repair.

17. COBBLER’S TECHNIQUE
• Following peribulbar anesthesia ,a fornix-based localized
conjunctival peritomy (6–11 O’clock) was performed in the
opposite site of the irdodialysis.
• Hemostasis of the scleral bed was achieved with wet field
cautery.
• A partial thickness scleral tunnel was created 1.5 mm from the
limbus along the extent of the iridodialysis.

18. • A limbal paracentesis is created and intracameral pilocarpine is
injected into the anterior chamber to place the iris tissue on
the maximal stretch.
• Sodium hyaluronate 1.4% is then injected to deepen the
anterior chamber.
• A 10- 0 polypropylene suture was threaded through a 26-
gauge needle.
• The 26-gauge needle was passed through the paracentesis and
the scleral groove engaging the root of the iris.

19. • The free end of the prolene suture is pulled out.
• The needle is withdrawn into the anterior chamber and taken out
at adjacent position engaging the root of the iris again.
• The prolene suture is pulled out forming a loop through which
the free end of the suture was passed to lock the loop.
• This step was repeated multiple times until multiple loops laid
over the scleral bed
• These loops were then tied and the conjuctival peritomy was
closed

21. KNOTLESS TECHNIQUE
• Under topical anaesthesia, a limbal conjunctival peritomy is
performed at the site of the iridodialysis.
• A paracentesis is created on the opposite side of the cornea.
One end of a double-armed 10-0 prolene suture on a straight
needle is introduced into the anterior chamber via the
paracentesis.
• The needle is then driven through the iris base.

22. • Penetration through the iris tissue and externalization of the
needle are facilitated by introducing a bent 27-gauge needle
through the sclera 1mm posterior to the limbus.
• Then the second arm of the prolene suture is introduced into
the anterior chamber via the same paracentesis and passed
through a second point of the iris base again using the 27-gauge
needle.

23. • The second arm of the prolene suture is introduced into the
anterior chamber through the sclera and the iris base and then
retrieved through the paracentesis.
• Steps are repeated as necessary to achieve complete apposition
of the iris base.
• At the end, the prolene suture is secured in the sclera using a
zigzag-shaped intrascleral suture (Z-suture).
• Five passes are needed, and each pass starts directly adjacent
to the exiting site, then the suture is cut without any knot.

25. SINGLE SUTURE CUSTOMISED LOOP
• Creation of partial thickness triangular scleral flap centered over
the dialysis area using a crescent knife
• Introduction of the first straight needle of a double-armed
polypropylene suture through the cornea and then through one
end of the dialysis, and then using a 27-gauge needle
introduced below the scleral flap 1.5 mm posterior to the
limbus as a guide track

26. • Introduction of the second polypropylene suture straight
needle through the cornea facing the other end of the huge
dialysis
• Withdrawing the two threads from the AC through the main
phaco wound using a Sinskey hook, forming two loops arising
from the main wound
• Cutting of the two loops; tying the cut ends together;

27. • Pulling on the two ends of the polypropylene loop from
beneath the scleral flap to reposit the iris back to its root;
• Pulling on one of the two suture ends to extrude the knot from
the AC;
• Pulling on the other suture in the opposite direction to correct
any wrinkles in the iris periphery that might have been caused
by the first pull;
• Tying the free ends of the sutures below the scleral flap; and
• Suturing the scleral flap with single nylon 10-0 suture at the
apex.

29. RIVETING TECHNIQUE
• Iridodialysis repair is performed using double-flanged
polypropylene suture.
• This method was first described by Drs. Mami Kuasaka and
Masayuki Akimoto from Japan.
• A scleral grove is created along the length of the iridodialysis. a
flange is created on one side of a 6-0 prolene suture.

30. • The bulbs are flattenned and a 30-gauge needle is used to
pull the suture through the anterior chamber and
iridodialysis.
• Additional flanges are made on the remaining end of the
suture to prevent slippage.

31. ALTERNATE IRIS BYPASS TECHNIQUE OF
IRIDODIALYSIS REPAIR
• A new technique which is inspired from the technique of hand
stitching of clothes
• Peritomy and scleral flap made corresponding to the extent of
iridodialysis
• Paracentesis made at the limbus opposite to the iridodialysis.
• Insertion of long needle of 10-0 prolene through sclera with
simultaneous insertion of 26 G long needle through the
paracentesis and passing 10-0 prolene needle into the edge of the
iridodialysis and then through the 26G needle

32. • Complete insertion of long needle of prolene into the 26G
long needle after taking out from the eye
• Passing 26G long needle (along with long needle of prolene
inside it) again through the paracentesis and inserting into the
sclera from inside out without passing through the iris
tissue which completes one cycle
• This cycle is repeated three times till it reaches the other end
of the iridodialysis and multiple loops of the suture are made

33. • Suture was tightened at both sides till the pupil becomes round
• Sutures are tied at both ends
• Scleral flap is sutured followed by peritomy closure

34. ADVANTAGE
• The edges of the iridodialysis can be visible till the end of the
repair by bypassing the iris tissue in alternate bites which helps in
minimizing the corectopia of the pupil and localized iris clumping.
• Tightening of the prolene suture can be done from both ends
until the pupil becomes round to avoid pupil eccentricity.
• No iris tissue incarceration in the wound due to alternate iris
tissue bypass during the passage of suture.

35. • Edges of the iridodialysis are attached to the sclera focally
only at the sutural site and there is no angle closure by the iris
tissue which can prevent risk of glaucoma post-surgery in
cases of large iridodialysis.
Disadvantages
• There may be the risk of suture getting cut while passing 26 G
needle into the sclera ab interno. Moreover, the ab interno
procedure is blind as there is no external guide to come out
exactly at the intended point.

36. Thank you