Eyeworld

EW NEWS & OPINION 12 Dr. Siepser, Siepser Laser Eyecare, Wayne, Pa., describes the sliding knot technique for patients with traumatic cycloplegia I n extreme cycloplegia, the iris collarette is retracted much like a cutworm or rolled-up sail. The damaged area is pulled back and furled underneath. While it may seem that this amount of dilation is too extreme to repair, a rather intuitive step-by-step ap- proach, the sliding knot technique, can be used to treat these patients. First, ocular preparation is per- formed as in any intraoperative pro- cedure, and the patient's head position and access should be simi- lar to that of a corneal transplant pa- tient, with multiple sites of entry. Initially all that is needed is normal topical anesthesia. Intraocular non- preserved lidocaine is irrigated into the anterior chamber to improve pa- tient comfort and four paracenteses are placed at the 2, 4, 8, and 10 o'clock positions created with a 15- degree diamond blade. The best po- sition is the oblique axes, however, and additional ports can be placed for convenience at any time or later in the case. Intraocular non-pre- served lidocaine is used again and left in the anterior chamber to fully anesthetize the iris. Viscoelastic is then injected 360 degrees through the different ports behind the iris, spreading and giving access to the furled up and retracted iris. Reconstructing the iris A straight Sinskey hook is intro- duced into the anterior chamber to begin teasing the opposite sector of the iris in a hooking and drawing fashion. In the other hand, a retinal grabber instrument is used to stretch the iris collarette on either side of the Sinskey. Once the iris edge is identified, the retinal grabber is used from the opposite paracentesis to ad- vance around the quadrants. No more than 2 mm of iris is stretched at a time and the iris collarette is carefully identified. A CIF-4 needle is introduced through a paracentesis that is lubricated with viscoelastic to ease the entry of the needle. Once August 2011 by Steven B. Siepser, M.D., F.A.C.S. Treating traumatic cycloplegia This extremely dense calcific nucleus was caused by a posterior capsular break in this traumatized eye Once the cataract was removed and all vit- reous and cortical debris cleaned, a retinal grabber was introduced across the eye, and an intraocular luminary probe was used to identify the iris collarette The pupillary margin is placed on great traction and the noted peripheral transillumination carefully observed to avoid dialysis The centered lens was placed 90 degrees away from the capsular break and was quite stable. The oblique paracentesis tract is used to approach the iris 180 degrees away from the incision sight. In certain circum- stances, two retinal instruments can be used in a hand-over-hand style I have found the Siepser sliding knot technique to be one of the most use- ful and ingenius methods of suturing tissue together within the anterior chamber. It allows knots to be created outside of the globe that are then pulled into the anterior chamber in an ex- tremely atraumatic means that avoids excessive tension on the iris root. It can be used to fixate IOL haptics to the iris or to repair iris defects. In this month's column, we are for- tunate to have Dr. Siepser review some tips and pearls for repairing traumatic mydriasis. His method is just one inno- vative means for creating a smaller pupil that will alleviate glare in these patients. In future columns, we will review the basic steps of creating the Siepser sliding knot using prolene sutures in ad- dition to reviewing other methods for repairing iris defects. I hope you find his article useful. Richard Hoffman, M.D. techniques editor the iris has been pulled and stretched to its maximum, the nee- dle is passed through the most ante- rior edge (1-2 mm bite is all that is needed). The pupil is created by al- ternating sides of the iris and using a divide-and-conquer method. For ex- ample, if a small bite is taken at 6 o'clock, the next bite would be taken at 12 o'clock. Working around the iris with small bites allows the centration and an anatomically cor- rect look to the iris. As the iris unfurls, the CIF-4 needle is introduced in one of the oblique paracenteses nearest the tar- get iris. It is passed by the most for- ward edge of the iris while the retinal instrument is as close as pos- sible, stabilizing the iris. The grabber is then used to grab 1-2 mm more of iris, creating the traction needed to impale the needle and transect the iris. The first pass is front-to-back and the second is back-to-front. The needle is then introduced into the waiting cannula. It is backed into the cannula, lodged there, and brought back out the opposite para- centesis. We then start working around the entire iris using the same Sinskey and grabber technique. We proceed a full 360 degrees to place as much iris as possible on stretch be- fore considering additional suturing. This can vary according to how the iris reacts to traction. The more di- aphanous or translucent the iris, the less traction it will support without tearing. A highly pigmented iris can withstand more traction but dialysis can be a problem. Reconstruction of the iris may not achieve the aperture needed but it is usually staged to get the maximum result. It is handy to have either a photo for reference or to see how the patient's other pupil appears under normal lighting conditions. Iris repair is usually staged. Getting rePlay online content Or view the video of Dr. Siepser's procedure at www.eyeworld.org/replay.php. Watch this video on your smartphone or iPad using your QR code reader. 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