Indications

Iridodialyses and iris sphincter tear, causing glare, photo-phobia, or cosmetically unacceptable anisocoria

Objectives

Preserve as much iris tissue and maintain as normal ocular anatomy as possible.

Reconstruct pupil to prevent glare and photophobia.

Restore a firm iris structure to avoid synechia formation and glaucoma.

Protect cornea (or corneal graft) from iridocorneal adhesions and glaucoma.

Create a stable iris diaphragm for support of anterior or posterior intraocular lens.

Preoperative Procedure

The initial treatment of iris injury is conservative until initial trauma repair is complete and wound is stabilized.

1. Shield (metal or plastic) the affected eye at all times.

2. Reduce pain and nausea to prevent lid squeezing.

3. Confine patient to bed rest and keep fasting (NPO) until time of surgery.

4. Administer prophylactic intravenous broad-spectrum antibiotics if appropriate

a. Cefazolin (1 g IV every 8 hours) and ciprofloxacin (400 mg IV 2 times per day) are a typical combination.

b. Clindamycin is added when an intraocular foreign body is suspected (for Bacillus coverage).

5. Tetanus toxoid as needed.

Nonsurgical Management

Sunglasses

Tinted contact lenses

Contact lenses with an artificial iris peripheral pigmentation

Topical medications

Miotic agents (e.g., pilocarpine 1%) may reduce size of a traumatically dilated pupil.

Mydriatic agents (e.g., cyclopentolate 1%) may normalize a decentered pupil.

Laser Treatments

Note: This technique is most useful when dilating drops are ineffective, where adhesions and bands can be lysed, and a sphincterotomy can recenter an eccentric pupil.

1. Argon laser settings: 50 μ (micron) spot size, power 1000 mW (milliwatts) power, 0.1 second duration; low risk of lens capsule rupture (can use in phakic patients).

2. Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser settings: 5 to 6 mJ and higher; higher rate of bleeding than argon laser.

Instrumentation

Lid speculum (e.g., Lieberman)

Fine-toothed tissue forceps (e.g., 0.12 mm forceps)

Westcott scissors

10–0 polypropylene sutures (with a long needle e.g., Ethicon CIF-4 for closed-chamber cases; Short needle e.g., Ethicon BV 100–4 for open sky cases)

Sutures (4–0 silk, 10–0 nylon, 8–10 Vicryl)

Needle holder

Smooth forceps (e.g., Chandler or Bracken forceps)

Viscoelastic material (e.g., Amvisc, Viscoat)