4 Cases of Surgical Iris Repair

Iris Repair complex

From CataractCoach.com: This young man sustained a terrible trauma which resulted in severe ocular trauma. A shard of glass penetrated his inferior limbus and damaged his iris and punctured his crystalline lens. He had an immediate repair of the ruptured globe with removal of the glass shard and a lensectomy. He then lived in this monocular status for a few years due to lack of access to healthcare. This resulted in sensory exotropia which compounded his problems. Can we do surgery to help him? Can we address multiple issues at the same sitting?

During extensive pre-op testing, we found that a contact lens in a power of about +12 resulted in a visual acuity of 20/40 with the limitation being the mild corneal irregularity which occurred with the initial trauma. However, with contact lens use, the patient had intractable diplopia which did not resolve. It was clear that a strabismus surgery would be necessary for this patient. The secondary IOL would help restore the vision without use of a contact lens, which the patient found difficult to tolerate for more than a few hours at a time. Finally, repairing the iris damage would result in a more physiologic pupil but also would dramatically improve the cosmetic appearance of the eye, which is particularly important to a young patient.

iris repair complex intraop
Figure: Three surgical procedures were performed at the same sitting: a monofocal IOL was suture-fixated to the sclera, a strabismus surgery was performed to straighten the eye (resection of the medial rectus and recession of the lateral rectus), and finally 10-0 polypropylene sutures were used to reconstruct the pupil. The iridoplasty should allow sufficient dilation for future retinal examination.

This patient underwent a surgical repair with a scleral-sutured IOL, pupilloplasty, and strabismus surgery to align the eye. After a few weeks of recovery, the patient looked great and more importantly, saw very well.

 

easy iris damage
Figure: This patient had an injury with the shell from a pellet gun which resulted in dis-insertion of the iris for two clock hours and a traumatic cataract. This is easier to fix since a single mattress suture can be used to secure the iris root to the angle. During cataract surgery beware that zonular damage may be present at the same area.

Sometimes iatrogenic trauma can be the cause of the iris damage. Particularly now, when so many of our patients present with IFIS (intra-operative floppy iris syndrome) due to Flomax (tamsulosin) use. The following patient had cataract surgery with severe floppy iris which resulted in sub-incisional loss of the iris and mis-placement of the IOL with the nasal haptic in the sulcus and the temporal haptic in the capsular bag. This resulted in de-centration of the IOL which resulted in poor vision along with dysphotopsias due to the corectopia.

IOLx with Iris repair

Other cases from blunt trauma are more difficult to repair. This young patient had a pellet gun injury which resulted in severe iris damage as well as rupture of the anterior lens capsule. A white cataract soon developed along with severe ocular inflammation.

severe iris damage
Figure: The surgical result is good, but not perfect. There are still two smaller areas of iris defect and an IOL is not as good as the crystalline lens in a young person. The patient recovered good vision and now uses protective eyewear when doing dangerous activities.

Watch the video below for instructions on how I performed the IOL exchange and then repaired the iris defect using 10-0 polypropylene suture to re-approximate the tissue.

 

Leave a Reply