Eyeworld

EW CATARACT 32 August 2017 Anterior segment grand rounds by Steven Safran, MD and McKee. The frayed area of iris was left in place, and the normal iris was sutured together with interrupt- ed 10-0 Prolene sutures to oversew the defective area. During this repair a buttonhole in the iris developed that needed to be repaired; the video demonstrates how that was done. The patient was very happy with the outcome of this procedure as she felt the eye looked better and her glare problem was completely resolved. you can need up with the knot embedded within the closure and sandwiched between the healthy and damaged iris. Done correctly, the repair would be difficult to spot even at the slit lamp. These are often some of the most grateful patients to have both a functional and cosmetic solution in one surgery." What was done The patient had a surgical repair using an oversewing technique as suggested by Drs. Hoffman, Snyder, Tennessee, said, "I would repair with McCannel sutures after removal of the diaphanous portion of the iris. Cosmetically it would be better but not perfect. It would eliminate the glare." Richard Hoffman, MD, Eu- gene, Oregon, commented, "I had a similar patient referred to me with bilateral temporal iris defects after a complicated phaco/IFIS OU. He had beautiful drawings of the nighttime glare in both eyes. I placed two interrupted 10-0 Prolene (CIF-4) su- tures using Siepser knots across the atrophic defect, and he demanded I do the other eye the following week. Very minimal pupil distortion, very happy patient." Michael Snyder, MD, Cincin- nati, said, "Temporal iris atrophy, like in this case, can be quite vexing since the entire defect is accessible to ambient illumination and the IOL edge is commonly hit by light as well. These defects most commonly occur from other thermal injury from the phaco probe in a dense lens or mechanical damage from iris prolapse, often from IFIS. Conser- vative measures such as sunglasses or opaque periphery contact lenses can be helpful in a small number of cases. When these measures fail, surgical options exist. Suture closure is usually possible in smaller defects like this one that are less than 2 clock hours. I prefer to use the oversew technique, since these defects can sometimes eventually cheese wire, and an oversew reduces the risk of having a greater defect than previously existed if cheese wiring does occur. Larger defects or ones in which the iris damage extends to the peripheral iris can be more difficult to suture and may require an iris prosthesis." Yuri McKee, MD, Mesa, Ari- zona, commented, "Based on your description and pictures I will assume that this is phaco damage to the iris and not some variant of ICE syndrome. Since there is less than 3 clock hours of damage, you should be able to do a primary iris repair by imbricating the healthy areas of iris across the damaged area. The whole surgery could be done with just two paracenteses. This would be a good case for an inverted mattress suture with a Siepser knot closure. By carefully planning the suture passes Patients with iris damage and defects after trauma or surgery often suffer from glare and are bothered by the cosmetic aspects of their problem. This article explores options for these patients I nitially there were quite a few responses advising against sur- gery as can be seen by a sample of responses below. "If I were to do anything— and I'm not sure I would—it would be a cosmetic contact lens," said Matt Goren, MD, Northwestern University Feinberg School of Medi- cine, Chicago. "I'd discuss iris painted CL and corneal tattooing. One might con- sider McCannel suture, but there's a risk of cheese wiring," comment- ed Garth Wilbanks, MD, Bangor, Maine. "If anything, corneal tattoo. But first try a contact lens," said Penny Asbell, MD, New York. There were others, however, who would consider a surgical approach. Erich Groos, MD, Cornea Consultants of Nashville, Nashville, Eye is frayed no more T his is a 56-year-old woman who came in for a second opinion after previous cataract surgery. She has a frayed, thin area of iris from 2 to 3 o'clock that transilluminates, and she is bothered by glare, especially while driving at night (Figures 1 and 2). She is also very unhappy with the appearance of this eye. She is inquiring if something can be done to reduce her glare symptoms and possibly to improve the appearance of the eye as well. I asked the members of Kera-net and the ASCRS EyeConnect cataract listservs—two very active online communities for anterior segment surgeons—what options they would offer this patient. Steven Safran, MD, ASGR editor Figures 1 and 2: The patient in the first case has a frayed, thin area of iris from 2 to 3 o'clock that transilluminates, and she is bothered by glare, especially while driving at night.

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