Complications Consult

Riveting with double-flanged polypropylene suture helps repair iridodialysis

A 30-gauge needle, 6-0 Prolene suture and low temperature cautery are essential to perform this technique.

Iridodialysis is often an accompanied clinical sign seen in cases with trauma. Occasionally it can be iatrogenic in nature, too. Numerous techniques have been described for the repair of iridodialysis. Mami Kusaka and Masayuki Akimoto from Japan recently described iridodialysis repair by riveting with double-flanged polypropylene sutures. The technique derives its inspiration from the flanged fixation of an IOL described by Shin Yamane.

Technique

A 30-gauge needle, a 6-0 Prolene suture and a low temperature cautery are essential to perform this technique. For flange creation, the needle is cut off from the suture end, and the suture is eventually cut into pieces of around 7 cm to 9 cm, depending on the amount of iris disinsertion. One suture piece is needed to approximate the iris at any one given point.

riveting flanged suture technique for iridodialysis
Figure 1. Clinical demonstration of riveting flanged suture technique for iridodialysis. A case of traumatic cataract with iridodialysis. Conjunctival peritomy is done, and a scleral groove is created along the length of the iridodialysis (a). A 6-0 Prolene suture end being heated with a low temperature cautery so as to create the flange (b). The suture flange is pressed and flattened (c). A 30-gauge needle is passed through the scleral groove and made to enter the anterior chamber, where it engages the peripheral iris tissue. The resistance to pass the needle can be provided by holding the iris with end-opening forceps. The flanged suture is threaded into the 30-gauge needle with the flange lying on the free end of the needle (d). The needle is pulled onto the scleral side, and this pulls the suture along with it, thereby approximating the flange close to the iris gap (e). The suture end on the scleral side is cut, and a flange is created. As the suture shrinks due to heat and the outer flange widens up, the inner flange draws closer to the iridodialysis gap and closes it (f).

Source: Priya Narang, MS, and Amar Agarwal, MS, FRCS, FRCOphth

One suture piece is taken, and a low temperature cautery is brought closer to the suture end so as to create a bulb. The bulb is pressed with forceps, and a flat flange is created (Figures 1a to 1c). Kusaka and Akimoto recommend making a bulb that involves heating the suture end up to 3 cm.

A scleral groove is made along the length of the iridodialysis, and a 30-gauge needle is passed from the scleral groove into the anterior chamber. The needle engages the peripheral base of disinserted iris, and the other end of the flanged suture is introduced from the corneal entry and is threaded into the 30-gauge needle. The needle is withdrawn, thereby pulling the suture along with it. The suture end is pulled, and the flange lies along the disinserted base (Figures 1a to 1f). The free end of suture on the scleral side is heated with a low temperature cautery, and a flange is created on the other side as well (Figure 2). Thus, the flanges on either side of the iris base hold the iris tissue to the sclera and prevent it from slipping (Figures 3 and 4).

needle is passed from the peripheral iris
Figure 2. Clinical demonstration of riveting flanged suture technique for iridodialysis. Similar procedure is performed again in which in the needle is passed from the peripheral iris, threads the flanged 6-0 Prolene suture and is withdrawn.
cut suture ends on the scleral side are flanged
Figure 3. Clinical demonstration of riveting flanged suture technique for iridodialysis. The cut suture ends on the scleral side are flanged. The bulb lies in the scleral groove and prevents it from slipping inside the anterior chamber (a and b). The flanged suture ends are seen. The flanges on either side hold the iris tissue to its base and cover up the iridodialysis (c). The conjunctiva seals the scleral groove and covers the suture flanges (d).

Thus, suturing of the iris to the base is not needed and is averted, thereby overcoming the complexities associated with suture knots.

Preoperative and postoperative images
Figure 4. Preoperative and postoperative images. Preoperative image of the case (a). Postoperative image depicting sealing of the iridodialysis wound (b).

Precautions

The suture bulb that is created should be neither too small nor too big. If the bulb is made much bigger, there is a chance that the bulb will hang down by its own weight. Too small a bulb will create a small flange that might not hold the iris tissue, and it might slip through the iris tissue and cut through it.

The low temperature cautery should be held at an ideal distance from the suture end. If it is held too close, then it might burn the entire suture material, which will eventually shrink and be rendered dysfunctional.

Disclosures: Agarwal and Narang report no relevant financial disclosures.

Iridodialysis is often an accompanied clinical sign seen in cases with trauma. Occasionally it can be iatrogenic in nature, too. Numerous techniques have been described for the repair of iridodialysis. Mami Kusaka and Masayuki Akimoto from Japan recently described iridodialysis repair by riveting with double-flanged polypropylene sutures. The technique derives its inspiration from the flanged fixation of an IOL described by Shin Yamane.

Technique

A 30-gauge needle, a 6-0 Prolene suture and a low temperature cautery are essential to perform this technique. For flange creation, the needle is cut off from the suture end, and the suture is eventually cut into pieces of around 7 cm to 9 cm, depending on the amount of iris disinsertion. One suture piece is needed to approximate the iris at any one given point.

riveting flanged suture technique for iridodialysis
Figure 1. Clinical demonstration of riveting flanged suture technique for iridodialysis. A case of traumatic cataract with iridodialysis. Conjunctival peritomy is done, and a scleral groove is created along the length of the iridodialysis (a). A 6-0 Prolene suture end being heated with a low temperature cautery so as to create the flange (b). The suture flange is pressed and flattened (c). A 30-gauge needle is passed through the scleral groove and made to enter the anterior chamber, where it engages the peripheral iris tissue. The resistance to pass the needle can be provided by holding the iris with end-opening forceps. The flanged suture is threaded into the 30-gauge needle with the flange lying on the free end of the needle (d). The needle is pulled onto the scleral side, and this pulls the suture along with it, thereby approximating the flange close to the iris gap (e). The suture end on the scleral side is cut, and a flange is created. As the suture shrinks due to heat and the outer flange widens up, the inner flange draws closer to the iridodialysis gap and closes it (f).

Source: Priya Narang, MS, and Amar Agarwal, MS, FRCS, FRCOphth

One suture piece is taken, and a low temperature cautery is brought closer to the suture end so as to create a bulb. The bulb is pressed with forceps, and a flat flange is created (Figures 1a to 1c). Kusaka and Akimoto recommend making a bulb that involves heating the suture end up to 3 cm.

A scleral groove is made along the length of the iridodialysis, and a 30-gauge needle is passed from the scleral groove into the anterior chamber. The needle engages the peripheral base of disinserted iris, and the other end of the flanged suture is introduced from the corneal entry and is threaded into the 30-gauge needle. The needle is withdrawn, thereby pulling the suture along with it. The suture end is pulled, and the flange lies along the disinserted base (Figures 1a to 1f). The free end of suture on the scleral side is heated with a low temperature cautery, and a flange is created on the other side as well (Figure 2). Thus, the flanges on either side of the iris base hold the iris tissue to the sclera and prevent it from slipping (Figures 3 and 4).

needle is passed from the peripheral iris
Figure 2. Clinical demonstration of riveting flanged suture technique for iridodialysis. Similar procedure is performed again in which in the needle is passed from the peripheral iris, threads the flanged 6-0 Prolene suture and is withdrawn.
cut suture ends on the scleral side are flanged
Figure 3. Clinical demonstration of riveting flanged suture technique for iridodialysis. The cut suture ends on the scleral side are flanged. The bulb lies in the scleral groove and prevents it from slipping inside the anterior chamber (a and b). The flanged suture ends are seen. The flanges on either side hold the iris tissue to its base and cover up the iridodialysis (c). The conjunctiva seals the scleral groove and covers the suture flanges (d).

Thus, suturing of the iris to the base is not needed and is averted, thereby overcoming the complexities associated with suture knots.

Preoperative and postoperative images
Figure 4. Preoperative and postoperative images. Preoperative image of the case (a). Postoperative image depicting sealing of the iridodialysis wound (b).

Precautions

The suture bulb that is created should be neither too small nor too big. If the bulb is made much bigger, there is a chance that the bulb will hang down by its own weight. Too small a bulb will create a small flange that might not hold the iris tissue, and it might slip through the iris tissue and cut through it.

The low temperature cautery should be held at an ideal distance from the suture end. If it is held too close, then it might burn the entire suture material, which will eventually shrink and be rendered dysfunctional.

Disclosures: Agarwal and Narang report no relevant financial disclosures.