A 20-year-old white female presented to our practice in June 1996 with an interesting traumatic history. At the age of 11, she had been struck in her right eye with a rotisserie rod, which resulted in the formation of a large, disfiguring coloboma. Because of her injury, this patient had been bothered by sunlight and by glare at nighttime, and troubled by the aesthetic effects of the coloboma. Due to this patient's blue irides, her iris coloboma was evident, and the pigment visible at 6-o'clock position caused consternation in her friends. She had been referred to our practice by a colleague who had heard me speak about repairing irides. This colleague thought that this patient's case was especially challenging because she had a normal, phakic eye with no lens opacities, and he wondered whether we could correct this pupillary aperture difficulty in front of her normal lens. Figure 1 demonstrates the large area of a colobomatous iris in front of a clear lens. The patient had high corneal astigmatism with BCVAs of 20/20 bilaterally. Her manifest refraction was -1.25 +0.75 X 115 OD and -4.00 +4.00 X 135 OS.
HOW WOULD YOU PROCEED?
1. Would you tell the patient that, after tolerating the condition for 9 years, it would not be worth treating now?
2. Risk creating a cataract in the left eye and causing possible injury to the capsule that would require additional surgery?
3. If you chose to perform surgery, where would you make the incisions for this procedure?
4. How would you repair the iris without distorting it?
5. What methods might you use to ensure that the pupillary aperture would be round and centered at the completion of surgery?
6. How would you deal with the astigmatism previously reported?
My colleagues and I carefully evaluated the right eye and noted that the pupillary aperture had an inferior temporal defect measuring approximately 5 mm across. The patient's topography demonstrated a high degree of corneal astigmatism consistent with our findings; it was unbalanced, and we planned to perform astigmatic keratotomies. There was also an area of darkened sclera lateral to the defect, which seemed to have incarcerated the iris.
In July 1996, the patient underwent the Siepser closed-chamber, slipping suture technique for iris repair to improve the centration of the iris.1 We divided the intervention into two parts: (1) correcting the area of iris scar inferiorly by removing pigment from the sclera, and (2) repairing the colobomatous region. We created a resection and a fornix-based flap inferiorly and removed the iris incarcerated in the conjunctiva and the superficial sclera. This treatment made the sclera appear clearer in this area and reduced the amount of pigment in the region.
Next, I made two stab incisions just above the pillars of the iris coloboma. I used a retinal forceps to stretch the iris pillar and break old synechiae (Figure 2A). I then passed the CIF-4 needle (Ethicon Inc., Cornelia, GA) through each pillar of the iris defect (Figure 2B and C). I passed the needle out of the wound so that a straight suture went in one side, down through the iris pillar on the proximal side, up through the iris pillar on the distal side, and back out of the paracentesis. Next, I grabbed and pulled the distal end of the suture to the proximal side, and performed a double-throw on the exteriorized loop of polypropylene (Figure 2D and E). I drew the loop back into the eye and used the distal suture to pull it back down over the iris defect (Figure 2F and G). I pulled this section taught and then downward to close the defect, and used another throw to square off the knot. I repeated this maneuver four times to create a better pupillary aperture (Figure 2H). I performed additional sphincterotomies to round the central iris and produce a large, reasonably sized central pupillary aperture.
The patient's postoperative UCVA improved to 20/40 over the 4 days following this initial surgery. By 6 months postoperatively, however, the patient's ocular performance had regressed to 20/200, and her corneal astigmatism seemed to stabilize at -4.00 +4.00 X 135. She underwent a repeat astigmatic keratotomy 2 years after her initial surgery in 1998, which reduced her astigmatism to -3.00 +4.00 X 143 and improved her UCVA to 20/100. Following another 6 months, the patient's UCVA improved to 20/80 with a refraction of -2.75 +2.75 X 143. With time, the iris repair migrated, and the patient's old corneal injury appeared less prominent (Figure 3).
Before considering repeat intervention to treat the patient's increasing astigmatism and pupillary displacement, we carefully evaluated her progress over several months to make sure her correction had stabilized. Once we were certain of the eye's stability, the patient underwent an additional iris repair with repeat sphincterotomies in 1998. During this procedure, we performed another set of astigmatic keratotomies that improved her UCVA to 20/50 with a refraction of -1.50 +2.00 X 155.
The patient remains very comfortable with her vision and is excited that she no longer suffers from a cosmetic and functional ocular problem. She has ceased to experience disabling glare and has been able to resume the outdoor activities she once enjoyed, including snowboarding and biking. Her vision presently functions normally.
Because this patient's astigmatism is now regular and orthogonic, LASIK is possible and would improve her UCVA even further.
Steven B. Siepser, MD, FACS, is Medical Director of Siepser Laser Eyecare in Paoli, Pennsylvania. He holds no financial interest in any product mentioned herein. Dr. Siepser may be reached at (610) 296-3333; firstname.lastname@example.org.
Michael Young, COA, is Head Technician at Siepser Laser Eyecare. He holds no financial interest in any product mentioned herein. He may be reached at email@example.com.
1. Troutman RC, Buzard KA. Corneal Astigmatsm: Etiology, Prevention and Management. St. Louis, MO: Mosby; 1992:252-253.