Eyeworld

24 | EYEWORLD | JULY 2021 ASCRS NEWS that compare long-term functional outcomes, cost-effectiveness, and accessibility of the dif- ferent iris repair techniques. The trends in the long-term implications of different iris repair strategies would require stratification based on the etiologies that underlie iris defects, whether they be congenital, traumatic, or iatrogenic, and the effects by co-occurring complications on outcomes of iris repairs. The choice of technique should be informed with a systematic consideration of the associat- ed risks to the patient. It would also be helpful to plan for surgical repair in cases of multiple types of iris defects; for example, if there was a case of simultaneous iridodialysis and sphincter damage, it may not be obvious which defect to first address. The section on intraocular knots is a useful overview, but a more detailed discussion with respect to the benefits and drawbacks of the various categories of knots would be welcome. A similar published review had a more nar- row scope but dove deeper into the historical context of these various knots and their relative utility. 11 Importantly, though the Siepser knot spares the iris potential traction induced trauma compared to the McCannel knot, many of the variations on the Siepser were published due to its technical difficulty. 12 Furthermore, other vari- ants have been published that are useful in spe- cific settings. There is a Siepser modification in which the knot lies posterior to the iris, which is useful in concomitant corneal transplants. 13 Overall, this review is a thorough summary of how to approach iatrogenic iris defects. It is a helpful overview for all cataract surgeons, but especially for those in the early stages of their surgical careers. The authors provided a helpful overview of the complexities involved in the difficult decision of whether to repair an iris defect caused during cataract surgery. In addition to gauging the potential visual significance and cosmesis of a given iris defect, the surgeon must consider the timing of surgical repair and his/her comfort level. The authors mentioned alternatives to surgical repair for cosmetically undesirable or visually significant iris defects. Keratopigmentation is an effective alternative to intraocular surgery. In a case series, 11 patients with moderate to severe visual dysfunction from iris defects and pupil abnormalities underwent manual intralamellar or femtosecond-assisted keratopigmentation with marked improvement in symptoms and acceptable cosmesis in all 11 patients. 8 Furthermore, newer micronized min- eral pigments have been shown to be non-toxic to the cornea. 9 Keratopigmentation may be an effective alternative to avoid a second intraoc- ular surgery in larger, more complex iatrogenic iris defects. The authors offered a systematic approach to the examination of the iris based on location and extent of the defect. While the options of iris repair are helpful to have in the surgeon's arsenal, it would also be important to consider the comparative safety profiles of the different techniques of iris repair. In a study of 50 eyes that underwent iridodialysis repair, Wan et al. demonstrated that eyes that underwent either hypodermic needle-guided suturing or dou- ble-armed suturing achieved similar outcomes of improvement in visual acuity, intraocular pressure, round pupil shape, and endothelial cell count by 6 months. 10 However, there are no multicenter and adequately powered studies continued from page 23 Management of common iatrogenic iris defects induced by cataract surgery Gary Foster, MD, Brandon Ayres, MD, Nicole Fram, MD, Sumitra Khandewal, MD, Gregory Ogawa, MD, Susan MacDonald, MD, Kevin Miller, MD, Michael Snyder, MD, Abhay Vasavada, MD J Cataract Refract Surg. 2021;47(4):522–532 The proximity of the iris to the instruments and currents of cataract surgery makes iatrogenic damage to the iris a common complication of cataract surgery. This paper discusses techniques to prevent or minimize this damage. When damage does occur, the surgeon must decide if, when, and how to repair the damage. Principles governing these decisions and techniques for repair are discussed. Figures and videos, included as online Supplemental Data files, illustrate cases of iatrogenic damage and repair techniques. Contact Khanna: Saira.Khanna@uchospitals.edu Veldman: pveldman@bsd.uchicago.edu References continued 9. Amesty MA, et al. Corneal tolerance to micronised mineral pigments for keratopigmen- tation. Br J Ophthalmol. 2014;98:1756–1760. 10. Wan W, et al. Comparing safety and efficiency of two closed-chamber techniques for iridodialysis repair – a retrospective clinical study. BMC Ophthalmol. 2018;18:311. 11. Lian RR, et al. Iris reconstruc- tion suturing techniques. Curr Opin Ophthalmol. 2020;31:43– 49. 12. Osher RH, et al. Modification of the Siepser slip-knot tech- nique. J Cataract Refract Surg. 2005;31:1098–1100. 13. Schoenberg ED, Price FW. Modification of Siepser sliding suture technique for iris repair and endothelial keratoplas- ty. J Cataract Refract Surg. 2014;40:705–708.

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