Nicole Fram, MD; Samuel Masket, MD; and Steven Naids, MD
Malpositioned or dislocated posterior chamber intraocular lenses (PCIOLs) are associated with significant visual discomfort and may lead to additional complications, such as uveitis-glaucoma-hyphema syndrome. A malpositioned 3-piece or single-piece PCIOL confined to the capsular bag may be repositioned and suture fixated to the sclera via a lasso technique of the haptics. However, iris suture fixation is ideal for repositioning a 3-piece PCIOL that is loose in the ciliary sulcus. In 1976, Dr. Malcom McCannel first described iris suture fixation to stabilize a subluxated multipiece IOL through a transcorneal approach.1 The Siepser sliding knot for iris repair was later applied and modified for fixation of a 3-piece PCIOL.2,3 Similarly, iris suture fixation of a foldable 3-piece PCIOL can also be applied to secondary IOL placement in the setting of aphakia.4–6 This is advantageous because it allows the surgeon to maintain a small incision and reduce the risks associated with larger incisions, such as surgically induced astigmatism and suprachoroidal hemorrhage.
In this chapter, we discuss our technique of iris suture fixation and provide recommendations for successful outcomes.
Preoperative Evaluation
Careful attention to iris structures during preoperative slit-lamp examination is important in determining the suitability for iris suture fixation of a subluxated IOL. First and foremost, there must be sufficient iris integrity. Thus, it is best to avoid this technique in eyes with significant iris atrophy or defects or a large degree of iridodonesis. Ideally, the patient will have some degree of sulcus capsular support, especially in post-vitrectomized eyes.
Anesthesia and Perioperative Considerations
Surgical technique begins with optimizing patient and surgeon comfort. A retrobulbar block is recommended with a 50:50 mixture of preservative-free lidocaine 2% and a longer-acting agent such as bupivacaine 0.75% to allow for adequate akinesia. We recommend using a 23-gauge x 1.5-inch Atkinson retrobulbar needle. Pupil management is a key consideration during iris suture fixation. Therefore, we do not routinely dilate patients preoperatively because it is necessary to induce miosis at strategic times during the haptic fixation procedure. Intracameral agents can be used to pharmacologically control the pupil size perioperatively and allow for flexibility of pupil size during surgery. Typically, the retrobulbar block allows for adequate pupillary dilation and visualization of the malpositioned PCIOL. If this is not the case, intracameral agents such as “epi-Shugarcaine” or preservative-free lidocaine (1%) with phenylephrine (1.5%) can be used to achieve proper dilation. Additionally, mechanical devices such as iris hooks may be helpful.
Figure 27-1. In this photograph, the haptic indentation of the iris is evident. Note the orientation of the suture pass toward the concavity of the haptic.
Basic Technique
Prior to surgery and intraoperatively, the extent of capsular support should be investigated along with the presence of vitreous in the anterior chamber. If vitreous is present, a triamcinolone acetonide–assisted anterior vitrectomy is performed. This can be done with or without a trocar-assisted pars plana approach 3.5 mm posterior to the limbus, in order to free the PCIOL from all vitreous adhesions prior to iris suture fixation. This reduces vitreous traction and the risk of potential retinal comorbidities such as retinal tears or detachment.
Multiple paracenteses are fashioned, and a dispersive ophthalmic viscosurgical device (OVD) is instilled into the anterior chamber to protect the endothelium during intraocular manipulation. OVD is also injected behind the malpositioned PCIOL to act as a barrier against vitreous prolapse. Next, serrated microsurgical 23-gauge forceps are used to grasp and bring the optic anterior to the iris in an optic capture position. Miochol (acetylcholine chloride) is then used to constrict the pupil to allow for stable optic capture and to facilitate iris suturing in a midperipheral location. The haptic indentations can typically be visualized through the iris due to the forced angulation caused by optic capture. If the location of the haptic is not easily identified, then one can lift the optic with a spatula or place OVD over the iris to better outline the haptic footprint. A 10-0 polypropylene suture (Ethicon CIF-4 needle) or 10-0 polyester suture (Alcon Laboratories, Inc PC-7 needle) is then placed through the cornea (via a paracentesis for the modified Siepser technique), through the iris, under the haptic, back through the other side of the iris, and out of the cornea at the limbus. It is easier to ensure that the haptic is engaged during the iris pass when the needle is passed toward the concavity of the haptic as described by Dr. Garry Condon (Figure 27-1). A 27-gauge docking cannula can also be used through a paracentesis to retrieve the exiting suture needle, ensuring a more controlled retrieval out of the eye.
Figure 27-2. This photograph demonstrates the proper orientation of the suture ends when tying a Siepser knot. (A) Distal end not engaging the iris. (B) Distal end engaging the iris. (C) Proximal end. (SimulEYE model created by Stuart Stoll, MD.)
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