3 Steps to Success with Pupilloplasty

3 Steps to Success with Pupilloplasty: (scroll down for video)

The iris is a strange tissue — very beautiful but at the same time, very delicate and finicky. It also responds to light and accommodation to constrict and dilate to maximize vision. Once it is significantly damaged, it cannot go back to being perfect, but we can surgically make it better.

3 steps pupilloplasty

After a careful pre-op analysis to determine the extent of the iris damage, tissue available, and potential issues, we can make a plan for repair. Keep in mind that pupilloplasty may not restore completely normal iris function, but it will certainly improve the function of a well-centered pupil which will result in better visual function for the patient. Of course, the cosmetic appearance will also be improved.

 

Step 1: Release adhesions to the iris

Using a 27 gauge blunt cannula we need to instill anesthetic inside the eye and release any iris adhesions. The iris may be stuck in the angle of the eye, on the cornea, or to the lens capsule. We need to carefully separate these adhesions using blunt methods such as with viscoelastic or with gentle traction with forceps. I favor using the small 23 or 25 gauge micro-forceps and micro-graspers since they can work via small 1 mm paracentesis incisions. Be very careful when pulling the iris because too much force will result in ripping the iris root which will result in more defects, bleeding, and worse.

Step 2: Instill acetylcholine solution

Once the iris tissue has been freed, we need to determine the muscular function by instilling a solution of acetylcholine (marketed as Miochol). This will cause constriction of the viable iris tissue and show us the atrophic tissue which won’t move. It is this atrophic iris tissue that needs to be sutured to reconstruct a round, centered pupil.

Step 3: Suture carefully

The iris tissue is weak and delicate. Pass sufficiently large passes of the 10-0 polypropylene in order to get a substantial bite of iris tissue. Keep in mind that since the iris is atrophic, it will tend to fall apart. Even a perfectly passed suture bite can cause cheese-wiring of the atrophic iris tissue. If there is a significant defect from cheese-wiring, it can also be sutured to further support the tissue and spread the tension among additional sutures.

pupilloplasty before and after pic
The left photo shows the extent of the corectopia and irregular iris before surgery. The right photo shows the results on post-op day 1 after pupilloplasty surgery. The result is improved function and cosmesis.

In the post-op period, these patients will have increased inflammation and will take longer to heal. Patience in the post-op period is required to see the final result. As long as your patients have realistic expectations, pupilloplasty is an excellent surgery to help restore function and appearance to damaged iris tissue.

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