Steven B. Siepser, MD, FACS
Historical Perspective
In 1874, the genetic transmission of iris defects was described by Herbert Page.1 The first description of iris abnormalities occurred in 1927.2 Macklin advised that people carrying these defects should not reproduce. As late as 1998, authors advocated tattooing the cornea to create aesthetic and functional improvement in eyes with large iris defects.3 In the years since the turn of this century, several reports of iris repair using mostly the Siepser sliding knot technique of iris sutures have been published.4 Before being published in the 1994 Annals of Ophthalmology,5 this unreferenced technique was first described at the 1990 Wills Eye Anterior Segment Cataract Conference in Key West, Florida, and then first cited in a 1992 Czechoslovakian Journal.
Until this time, sector iridectomies in the setting of intracapsular cataract extractions were de rigueur and considered the best way to ease the entire cataract out of the eye. It was considered far safer to perform a sector iridectomy when removing a cataract than to take chances with a “round” pupil extraction. The naissance of iris repair happened in a stepwise approach.
This is how things were done in the 1970s. Dr. Edwin Tait, my senior associate, spent his career doing intracapsular cataract extractions with sector iridectomies. He stopped operating about the time that I started. During those last few procedures performed with Dr. Tait, I used a round pupil technique, which was improved with Kelman’s cryoextractor (Figure 67-1). As my associate slowly reduced his practice, aphakic patients started showing up. I was already well on my way performing extracapsular cataract extractions with intraocular lenses (IOLs).
As a young man, I had a big interest in photography and instinctively knew that the smaller the visual aperture, the better the depth of field. It stood to reason that reducing the pupillary aperture in human eyes would improve visual function—a thought that was not well accepted at the time. Malcolm A. McCannel, a true pioneer of the times, was among the first to propose the idea of manipulating the iris to repair a defect. I began doing secondary lens implants and it was not long before I realized that proper closure of the pupil had become a necessary component for IOL surgery. At first I used a McCannel-type suture but could only manage to place one single iris suture because it was difficult to get the iris pillars to the incision site.
Once I developed the Siepser sliding knot, more sutures could be added in any meridian of the defect without overtensioning the iris. I became confident that I could close superior iridectomies on the hundreds of patients for whom I implanted secondary implants. In the early days, I used an ab interno process of just lassoing the loops and externalizing the sutures. Other authors have covered a multitude of ingenious ways to fixate IOLs when there is no capsular support. Techniques have advanced to provide surgeons with a multitude of options using different implants and procedures that can be matched to the particular needs of each patient. It took me a while to start repairing the iris in phakic eyes. After gaining confidence repairing superior iridectomies, I could navigate around the eye to correct an iris defect in any meridian. It is perplexing and discouraging that even today closing iris defects in phakic eyes is still not widely accepted.
Figure 67-1. This is how it was!
Figure 67-2 shows the first phakic patient in whom I attempted an iris defect repair. The surgery was performed 20 years ago. She had been hit with a fire poker that caused a traumatic iris coloboma. Recently, this young woman returned from Denver to have her cataract removed. Her sutures had partially cheese-wired through the iris over the past 2 decades. This additional iris surgery and the previous trauma likely precipitated her early cataract. The iris repair procedure was life changing for her because due to the cosmetic appearance of her eye, she had become a bit of a teenage recluse. Once her iris was repaired, she became quite extroverted, ventured out more, moved to Colorado, and started snowboarding. It is important that such patients are able to find surgeons interested in performing these iris repair techniques. Too many suffer visual and emotional disabilities because doctors tell them “nothing can be done” or discount the value of having a normal cosmetic appearance of the eye.
David Chang was among the first to publish the technique of using the Siepser sliding knot for suture tying within the eye, specifically, iris-haptic fixation.6 It became possible by changing direct access knot tying over the defect with a McCannel-style suture. When Dr. Chang was presented with a traumatic cataract accompanied by a gaping iris defect, he first practiced the slip knot using a heavy string at home. It worked miraculously to close the defect without stretching the iris base (which direct externalization of the knot would have done). His remarkable video of it was shown at a University of California—San Francisco alumni meeting. Seeing the knot slide the first time always elicits a wow moment (lots of gasps).
Dr. Chang used the same technique, McCannel + Siepser, for fixating a haptic to the iris. This prevents rotation or subluxation of a 3-piece sulcus-supported IOL. He published a series of these cases in 2004. At that time, Garry Condon was independently using the slip knot for iris-haptic fixation in the absence of any posterior capsule. Dr. Chang and Dr. Condon were the first to publish their work. As a result of their lectures and publications, the slip knot technique became popularized in subsequent years.
Figure 67-2. (A, B) A reclusive 18-year-old patient struck in her left eye with a fire poker that caused a traumatic coloboma as a 6-year-old. This restorative surgery was reported to open her up to the world.
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