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16 EW NEWS & OPINION A case continued from page 15 gery using four paracentesis inci- sions, 10-0 prolene on a CIF-4 needle, MST (Redmond, Wash.) microforceps, and a 27-gauge can- nula to help guide the needle out of the paracentesis incisions. An attempt was made to have as many superficial, small bites in the iris stroma as possible to make the pupil appear round rather than ragged and to allow easy removal of the suture down the road if necessary to permit treatment of the retina. I discussed the optimum pupil size to target in a case like this with a retina colleague, Kekul Shah, M.D., Lawrenceville, N.J., who com- mented: "I think a 3.5- to 4.0-mm pupil would be the ideal size to allow minimal glare and excellent cosmesis without hindering the abil- ity of a vitreoretinal surgeon to accu- rately evaluate, diagnose, and treat diseases of the posterior segment. I also believe that the aforementioned size would allow for adequate visual- ization during posterior segment surgery especially with modern wide-angle view systems." This (3.5-4.0 mm) is the pupil size I targeted, and I used a McCan- nel-type suturing technique com- bined with intraocular tightening of the purse string with an MST forceps to try to achieve this goal. It is tempting to make the pupil as small as possible when one is tying the su- ture, and I think it's wise to resist this urge. One has to be careful when doing the second locking throw in the McCannel suture not to apply too much tension that will bring the pupil down further as it will be difficult or impossible to re- verse at that point since the suture can't be loosened once locked. The video can be viewed at http://youtu.be/PkYpnRzh2iQ. The patient ended up 20/25-2 with a –1.0 refractive error despite a history of a macula-off retina de- tachment. She is very pleased with the appearance of the eye, although she is hoping the visual acuity will continue to improve as it is not yet as clear as it was prior to her retina detachment. I also asked Dr. Shah to give the perspective of a retina specialist about the use of a silicone iris pros- thesis in a patient like this. He com- mented: "In an eye that has had trauma or loss of iris tone after com- plications from intraocular surgery and that may need further posterior segment intervention, I would prefer that intraocular silicone-based mate- rials not be used due to the likeli- hood of silicone oil adhesion. The development of oil droplets on the surface of the implant usually re- duces the optical quality for both the patient and examiner. In gen- eral, if the silicone iris prosthesis was placed in a manner that was easily removable like the ciliary sulcus and not sutured in place, I'd be more comfortable with its use in an eye that might need vitreoretinal sur- gery in the future." I am hoping that the HumanOptics (Erlangen, Germany) silicone iris prosthesis will be ap- proved by the FDA in a timely fash- ion and that we will have access to it. This case demonstrates that even when this device is readily available, there will still be a place for surgical iris repair. This technique is an excellent one for anterior segment surgeons to master. EW Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Safran: safran12@comcast.net April 2012