9 Single-Pass Four-Throw Pupilloplasty
Summary
Single-pass four-throw pupilloplasty is a surgical technique that involves passage of the 10–0 suture needle only once through the anterior chamber (AC) and involves taking of four throws through the loop withdrawn from the AC. The technique creates an approximation of loop that has a self-retaining and a self-locking mechanism.
9.1 Introduction
Pupilloplasty procedures are aimed at restoring the configuration of the iris contour, thereby preventing any hindrance to its functionality and cosmetic aspect. Iris defects may be congenital, traumatic, or may be induced iatrogenically during the intraocular maneuvers. Irrespective of the etiology of iris defect, it needs to be surgically corrected as conformation of the shape and size of the pupil to the normal configuration is extremely essential to avoid unpleasant outcomes like glare and photophobia.
In 1976, McCannel introduced the concept of iris suturing within the confines of the anterior chamber (AC) by creating corneal paracentesis incisions. 1 The flaw with the procedure was that the iris tissue was often overstretched and it was a bit inconvenient to perform. Modified McCannel technique overcame this aspect although it also required intraocular manipulation of suture thread to tie the knot. 2 Siepser’s introduced the slipknot technique 3 that was further modified by Osher et al and was known as modified Siepser’s knot. 4 Single-pass four-throw (SFT) technique 5 is the newer variant in the arena of pupilloplasty procedures and is also a modification of the modified Siepser’s slipknot technique, wherein only one pass is made into the AC with four throws taken around the loop of the suture.
9.2 Surgical Technique
9.2.1 Principle
A surgical knot comprises an approximation loop initially followed by a securing knot. The SFT technique comprises only the approximation loop and a second pass to take the securing knot is not taken. In the creation of the initial approximation loop, four throws are taken and a helical configuration is created that frames a secured knot that is self-locking and self-retaining (▶Video 9.1).
Under peribulbar anesthesia, two paracentesis incisions are created and a 10–0 suture attached to the long arm of the needle is introduced into the AC. An end-opening forceps is introduced through the paracentesis incision and the proximal iris leaflet is held. The 10–0 needle is passed through the proximal iris tissue (▶Fig. 9.1a, b). A 26-G needle is introduced from the paracentesis incision from the opposite quadrant and is passed through the distal iris leaflet after being held with an end-opening forceps. The tip of the 10–0 needle is then passed through the barrel of the 26-G needle that is then pulled out from the paracentesis incision (▶Fig. 9.1c–e). This also pulls the 10–0 needle out of the AC along with the 26-G needle.
A Sinskey’s hook is passed through the paracentesis incision and a loop of suture is withdrawn from the eye (▶Fig. 9.1f, ▶Fig. 9.2a ). The suture end is passed through the loop four times, that is, in a way, four throws are taken through the loop taking care to pass the suture through the loop in the same direction (▶Fig. 9.2b, c). Both the suture ends are pulled and the loop slides inside the eye approximating the iris tissue edges (▶Fig. 9.2d, e). The suture ends are then cut with a microscissors (▶Fig. 9.2f). The procedure is then repeated in the second half quadrant to achieve a pupil of the desired configuration.
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