What is the management for iridodialysis during Small Incision Cataract Surgery (SICS)?

Management of Iridodialysis During Small Incision Cataract Surgery (SICS)

If iridodialysis occurs intraoperatively during SICS, immediately repair it using direct suture reapproximation techniques with double-armed 10-0 polypropylene suture to prevent postoperative complications including diplopia, glare, photophobia, and secondary angle closure.

Immediate Intraoperative Recognition and Assessment

• Assess the extent of iris disinsertion - small dialyses (<2 clock hours) may be asymptomatic and potentially observed, while larger defects (>2-3 clock hours) require immediate surgical repair to prevent iris necrosis, pigment dispersion, and secondary glaucoma 1

• Evaluate for associated complications - check for zonular dialysis, vitreous prolapse, or lens subluxation that may have occurred concurrently with the iris trauma 1

• Document the location and size - superior dialyses are often better tolerated than inferior ones, but extensive defects in any location will cause polycoria, corectopia, diplopia, and photophobia requiring repair 2, 3

Surgical Repair Techniques During SICS

Primary Suture Repair (Preferred Method)

Use double-armed 10-0 polypropylene suture with straight needles to directly reapproximate the iris root to the scleral spur - this is the gold standard for intraoperative iridodialysis repair 3, 4

• Pass the first needle from inside the anterior chamber through the peripheral iris near the dialysis edge, then externalize through a scleral tunnel or intrascleral pass approximately 1.5-2mm posterior to the limbus 3

• Pass the second needle through the opposite edge of the dialysis in a mattress suture configuration to achieve proper iris reapproximation 4

• Use the "alternate iris bypass technique" where you take alternating bites through the iris tissue, which keeps the dialysis edges visible throughout the repair and minimizes corectopia and localized iris clumping 5

• Create intrascleral passes to bury the suture - this avoids external knots and reduces long-term risk of suture erosion, particularly important as these repairs must last decades 3

Novel Transconjunctival Knotless Technique

Consider the transconjunctival, intrascleral, ab-externo, double-flanged technique with 6-0 Prolene for extensive iridodialysis - this avoids conjunctival peritomy, scleral incisions, and external knots 2

• This technique is less time-consuming than traditional methods and has shown good 1-year outcomes 2

• The knotless approach eliminates concerns about suture erosion through conjunctiva or sclera 2

Gas Tamponade for Near-Total Disinsertion

For near-total iris disinsertion (>270 degrees), inject isoexpansile sulfur hexafluoride (SF6) gas intracamerally after completing phacoemulsification and IOL implantation to tamponade and preserve iris position 1

• This technique is particularly useful when suture fixation becomes technically impossible due to the extent of disinsertion 1

• The gas provides temporary support while the iris heals in anatomic position 1

Management of Associated Angle Closure Risk

Monitor for secondary angle closure mechanisms that can develop after iridodialysis, as peripheral anterior synechiae (PAS) may form following anterior segment surgery 6

• Perform gonioscopy postoperatively to assess for angle closure or PAS formation 6

• Consider prophylactic measures if pupillary block develops - though this is uncommon with iridodialysis (which typically creates an alternate aqueous pathway), combined trauma may create mixed mechanisms 6

Postoperative Considerations

Prescribe topical corticosteroids and cycloplegics to reduce inflammation and prevent posterior synechiae formation while the iris heals

Warn patients about potential complications including:

• Residual diplopia or glare if repair is incomplete 2
• Risk of pigment dispersion and secondary glaucoma 1
• Possible need for revision surgery if initial repair fails 2

Schedule close follow-up at 1 day, 1 week, and 1 month to monitor for:

• Suture integrity and iris position
• IOP elevation from inflammation or angle compromise
• Development of corectopia or residual polycoria 5

Common Pitfalls to Avoid

• Do not leave large iridodialysis unrepaired - even if the patient seems asymptomatic intraoperatively, postoperative symptoms of diplopia, glare, and photophobia are highly likely with defects >2-3 clock hours 2, 3

• Avoid excessive iris manipulation during suture placement as this can cause additional trauma, bleeding, and inflammation 3

• Do not use absorbable sutures - permanent 10-0 polypropylene is required for durable long-term repair 3, 4

• Ensure adequate visualization before attempting repair - if corneal edema obscures the view, consider using intracameral viscoelastic or topical hyperosmotic agents to clear the cornea 6