Progressive peripheral anterior synchiae following penetrati ng keratoplasty is an ominouscomplication. ' Secondary angle closure glaucoma can be difficult to control and can result in irreversible loss of vision. In order to prevent such progressive synechia! closure of the peripheral angle in patients with flaccid irides, the iris was sutured at the time of the corneal transplantation to create a taut iris. We report here our experience with 20 patients who had iridoplasties and have been followed for a minimum of nine months.
PATIENTS AND METHODS
Patients: Twenty patients with extensive surgical or traumatic iris loss and/or iridocorneal synechiae had iridoplasties done in the course of corneal transplantation. The preoperative diagnosis for the patients is listed in Table 1. Seventeen patients were aphakic, with four of these being Pseudophakie. In nine patients the pupil was round; in eleven, a sector iridectomy was evident. In all cases intraocular pressure was adequately controlled, although two patients required glaucoma medications. The condition of the filtration angle as judged by slit lamp biomicroscopy and gonioscopy is listed in Table 2.
Operative technique: Using standard techniques, we removed the corneal button, and an anterior vitrectomy, if indicated, was performed. When peripheral anterior synechiae (PAS) or irido-corneal synechiae were present, synechiolysis was attempted using a cyclodialysis spatula. When the synechiae could not be easily lysed, the iris was cut on both sides of the PAS in order to reduce the risk of subsequent synechial formation (Figure 1). The iris was sutured together in one location in 1 5 patients and in two locations in 5 patients using one or more interrupted 10-0 nylon sutures placed near the iris sphincter (Figures 1 , 2, & 3). Sector iridectomies were closed to recreate a round pupil. If the edges could not be apposed without excessive tension on the iris, the suture was tied loosely. Flaccid irides in the presence of otherwise round pupils could be made more rigid by performing "tucks" with one or more interrupted sutures placed near the iris sphincter.
Postoperative Follow-Up: Patients were followed for a minimum of nine months. Postoperative intraocular pressure (measured using the Goldmann applanation tonometer and/or Digilab pneumotonometer), the depth of the angle, and glaucoma treatment were recorded at regular follow-up examinations. Whenever possible, gonioscopy was performed.
All iridoplasty sutures have remained intact during follow-up intervals ranging from nine months to seven years (median, 14 months). No deterioration or separation of these nylon sutures has been observed, and thus the use of prolene suture seems unnecessary for this purpose. There have been no complications associated with the presence of the iris suture.
Postoperatively, 16 of these 20 patients, including nine with preoperative PAS, have a deep chamber without evidence of progressive PAS formation (Table 2). Four other patients developed progressive PAS associated with elevated intraocular pressure. Of those four patients, three had PAS preoperatively. Thus, only one patient without preoperative PAS developed PAS following surgery.
The preoperative diagnosis in the four patients who developed secondary glaucoma were corneal perforation due to keratitis sicca (one patient), aphakic bullous keratopathy (one patient), and Pseudophakie bullous keratopathy (two patients). In three patients, the intraocular pressure was medically controlled. One patient developed a flat peripheral chamber for 360° and required cyclocryotherapy to achieve adequate glaucoma control. In no case was the iris adherent to the graft wound or to the donor cornea.
FIGURE 1: Iridoplasty technique in cases with preoperative PAS. Left: Iris with PAS from 9:30 to 1 1:30 o'clock position and large, irregular pupil. Middle: Iris cut on both sides of PAS and included sector excised (dotted line). Right: Cut iris edges sutured together with two interrupted sutures.
FIGURE 2: Left: Aphakic bullous keratopathy with sector iridectomy. Middle: Seven years after penetrating keratoplasty with iridoplasty. Right: Higher magnification view of iris suture.
RESULTS: PERIPHERAL ANTERIOR SYNECHIAE (PAS)
FIGURE 3: Left: Corneal laceration with traumatic iris loss. RightTwelve months after penetrating keratoplasty with iridoplasty.
A taut iris diaphragm can be created by suturing a flaccid iris at the time of corneal transplantation. Troutman has described a similar technique using a prolene suture.2 Schepens has performed iris suturing in the course of open-sky vitrectomy to aid reformation of the anterior chamber and to avoid postoperative anterior irissynechiae.' Pallin has reported a closed technique for suturing the iris to create a round pupil when iris atrophy is present.4
In recent years, the use of oversized grafts,5 hyaluronic acid,6 and postoperative steroids1 has been advocated to prevent postoperative pressure elevation, angle closure, and glaucoma following keratoplasty. Postoperative inflammation is the major cause of angle closure. Aphakic, and particularly Pseudophakie,7 eyes are especially likely to develop PAS. A traumatically or surgically flaccid iris is an additional anatomic factor that predisposes to PAS formation. We think that the creation of a more rigid iris diaphragm, in addition to the above modalities, may benefit patients who are at high risk for synechial angle closure following penetrating keratoplasty.
Our experience with iridoplasty is difficult to compare in a controlled manner. No estimates are available from the literature concerning the development of progressive PAS following keratoplasty. However, in a brief retrospective analysis of an additional 40 keratoplasty cases with similarly extensive surgical or traumatic iris loss and/or iridocorneal synechiae, the prevalence of progressive PAS was 45% (18/40) in those for whom no iridoplasty was performed, and was 20% (4/20) in the iridoplasty series. In any event, as the iridoplasty procedure is brief, technically simple, and not associated with operative or postoperative complications, we believe that this useful surgical maneuver is justified in these situations.
1. Thoft RA, Gordon JM, Dohlman CH: Glaucoma following keratoplasty. Trans Am Acad Ophthalmol Otolaryngol 1974; 78:0P 352-364.
2. Troutman RC: Microsurgery of the Anterior Segment of the Eye. vol Il St Louis, CV Mosby, 1977, pp 144-147, 260-261 .
3. Schepens CL: Clinical and research aspects of subtotal opensky vitrectomy. Am J Ophthalmol 1981; 91:143-171.
4. Pallin SL: Closed chamber iridoplasty. Ophthalmic Surg 1981; 12:213-214.
5. Zimmerman T, Olson R, Waltman S, et al: Transplant size and elevated intraocular pressure. Arch Ophthalmol 1978; 96:2231-2233.
6. Polack FM, Demong T, Santaella H: Sodium hyaluronate (Healon") in keratoplasty and IOL implantation. Ophthalmolgy 1981;88:425-431.
7. Rowsey JJ, Gaylor JR. Intraocular lens disasters: Peripheral anterior synechia Ophthalmology 1980; 87:646-664.
RESULTS: PERIPHERAL ANTERIOR SYNECHIAE (PAS)