To elaborate the modified closed-chamber technique with ICCE in managing subtotal iridodialysis with traumatic cataract due to contusion ocular trauma.
Iridodialysis repair with modified double armed closed chamber technique
1. dr. RIDHO RANOVIAN
Consultant:
Prof. Dr. dr. Tjahjono D. Gondhowiardjo, SpM(K)
Department of Ophtalmology
Faculty of Medicine University of Indonesia
Cipto Mangunkusumo – Kirana Hospital
October 2019
Modified Closed-Chamber, Double-Armed, Cross-Pupil
Technique in Managing Subtotal Iridodialysis
due to Contusion Ocular Trauma
A CASE REPORT
3. Ocular trauma : a significant cause of blindness and often affects
productive young individuals.
A population-based study in USA : prevalence rate of ocular trauma at 19.8%
and average annual incidence rate of 3.1 per 1000 population.
Nuraini at Cipto Mangunkusumo Hospital :
57% ocular trauma cases annualy at ER with 58.9% of the patients
were on productive age (20-55 years old), blunt trauma (45.7%)
followed by sharp object-related trauma (32%).
4. • Iridodialysis commonly occurs secondary to blunt or
penetrating trauma, and intraocular procedures
• Glare and monocular diplopia
• Commonly coexists with traumatic cataracts and zonulysis
• Several iridodialysis repair techniques have been published,
how to choose the proper one?
5. AIM
To elaborate on the modified closed-chamber, double-
armed, cross-pupil technique in managing subtotal
iridodialysis with ICCE for traumatic cataract
7. Male, 55 Y.O
FIRST VISIT
Pain and blurred vision of left eye
VAOS : HMGP
IOP : 39 mmHg
• Corneal erosion
• Iridodialysis at 8 to 4
o’clock meridian
• Hazy lens with
phacodonesis
11. Post operative outcome
One day post-operative
• VAOS : HMGP
• IOP : 16 mmHg
• Cornea : edema, desc fold (+)
• AC : deep, coagulum (+), fibrin (+)
• I/P : attached, irregular, fixed dilated
• Aphakic
• V/F : hard to be evaluated
Plan:
• Methylprednisolone 3 x 4 mg orally
• Prednisolone asetate ED 6 x LE
• Levofloxacin ED 6 x LE
16. • The mechanism of trauma whether closed or open, blunt, penetrating, or perforating, force
and extent of trauma, and whether a foreign body is involved determine the pathophysiologic
consequences of injury to the various anterior segment structures.
• The patient was presented to our clinic with history contusion ocular trauma caused by a hit
by a piece of metal object. There was only corneal erosion which managed by wearing
bandage contact lens and confirmed healing after a week follow up.
18. IRIDODIALYSIS
• Iris is rich of blood vessels as it forms
the bulk of the iris stroma with most
follow a radial course that arise from
the major arterial circle
• Avulsion of the iris from its natural
insertion on the ciliary body
20. OUR CASE
• Blurred vision after ocular contusion, at the beginning he
felt glare, photophobia and monocular diplopia
• A subtotal iridodialysis from 8 to 4 o’clock meridian with
traumatic cataract formation of his lens with zonulysis
21. IRIDOPLASTY TECHNIQUE
• Open-system approach
– through a limbal self-sealing incision or a scleral tunnel incision
by making a full-thickness scleral incision.
26. • Most of meridian of detached iris had been
reattached to the internal scleral wall.
• Minimal iridodialysis at 7 o’clock and 2-5 o’clock
• In this case, we have to perform ICCE procedure for
cataract extraction because there is phacodonesis which
indicate zonulysis of the lens.
• There is no iris atrophy, means this tissue is still
viable.
27. Secondary glaucoma due to contusion ocular trauma
• Recessions greater than 180° are associated with a 4-9% incidence
of glaucoma.
• Eyes with angle recession of greater than 240° appear to be at the
highest risk of chronic glaucoma
29. conclusion
• Iridodialysis is one of the most severe complications of ocular
trauma.
• Iris trauma commonly coexists with a traumatic cataract
with possible injury to the zonules. It also can lead to
secondary glaucoma.
• Repair technique depends on how large the iridodialysis
occurred, the remaining iris attached, the operator
experiences, and skills.
• Comprehensive management
Aslm. Wr.wb. Good morning to all consultants, fellows and residents. Today I would like to present my case presentation with title “Modified Closed-Chamber, Double-Armed, Cross-Pupil Technique in Managing Subtotal Iridodialysis
due to Contusion Ocular Trauma : A case report
”
as the introduction
As the introduction..
Ocular trauma remains a significant cause of monocular visual loss and blindness and often affects productive young individuals. 1
A population-based study in the USA reported a prevalence rate of ocular trauma at 19.8% of all trauma cases and average annual incidence rate of 3.1 per 1000 population.
This study also reported The workplace has traditionally been the most common site of ocular trauma happened.
A descriptive study by Nuraini3 conducted at Cipto Mangunkusumo Hospital reported that in a year there were 57% ocular trauma cases that visit to emergency room with 58.9% of the patients were on productive age (20-55 years old), the leading cause of the trauma was blunt trauma (45.7%) followed by sharp object-related trauma (32%).
Iridodialysis commonly occurs secondary to blunt or penetrating trauma, and intraocular procedure
Iridodialysis can present both pupillary function and cosmetical problems to the patient. Functional symptoms, such as glare and monocular diplopia, result from the polycoria of a pseudo-pupil created by the iridodialysis.
and most commonly seen when iridodialysis is located in the nasal, temporal or inferior quadrants.
Iris trauma commonly coexists with traumatic cataract and zonulysis.
Several surgical techniques in managing iridodialysis have been published.
but how to choose the proper one?
In this case report, we will present a case of subtotal iridodialysis with traumatic cataract with visual acuity limited to hand movement, and the patient underwent intra capsular cataract extraction (ICCE) and iridoplasty surgery
This case report aim….
And this is the case illustration of our patient..
At 1st visit A 55 years old male was presented to Corneal Refractive Surgery (CRS) clinic Kirana Ciptomangunkusumo Hospital with chief complaint a five days history of pain and a blurred vision of the left eye after he was hit on the left eye by a piece of the bouncing broken nail .There was few blood discharge from his left eye at the moment.
At this initial visit the visual acuity was HMGP with IOP 39 mmHg.
There was corneal erosion at nasal paracentral, 1/3 stromal depth, 3.4 mm x 1.6 mm in size with staining
The major problem is the large iridodialysis at 8 to 4 o’clock hour meridian. The second problem was the lens which totally hazy with phacodonesis, so the funduscopy was hard to be evaluated
So we performed The orbital ultrasound (USG) of the left eye showed the high-density lens and quite posterior segment, also there were no sign of retinal detachment or intraocular foreign body at this moment
so we assest this patient with..
and we managed this patient with
we planned this patient to undergo ICCE + Iridoplasty
wore BCL
also prescribed
The surgery was performed under local anesthesia using topical 2% tetracaine ED and 2% lidocaine subconjunctival injection. Peritomy 180o was made on superior quadrant and bleeding was controlled by cauterization.
Slit corneal incision was performed at 11 o’clock hour position. Then, tryphan blue was injected to anterior chamber
Scleral grooving was performed from 10 o’clock hour to 2 o’clock hour meridian parallel to the limbus about 2-3 mm posterior to limbal margin. A lamellar scleral dissection was made using disposable keratome to penetrate anterior chamber, then the incision expanded using corneal scissor. Anterior vitrectomy was performed to clean off the vitreous. Sodium hyaluronate viscoelastic was injected to anterior chamber. Then the entire lens body was extracted using lens loop, and corneal-scleral suturing with nylon 10-0.
The iris repairing technique used was a closed system, double-armed, cross-pupil technique with scleral and corneolimbal approach.
The first needle entered at the main port to the 10 o’clock meridian passed through the iris base, penetrate the detached iris and sewed back to the sclera, then it penetrates the sclera again 1-2 mm from the other scleral site, penetrate the iris and the straight needle exit the anterior chamber from the main port.
Pulling on the two ends of the polypropylene loop from beneath the main port to reposit the iris back to internal scleral wall then the excess sutures were tied over bare sclera to make a knot. The slip knot was made and the excessive suture was cut.
Repairing the dialysis at 2 – 4 hour meridians were made through transcorneal insertion from its opposite meridian then the knot was made outer the sclera at dialysis position.
Detached iris at 12 - 3 hour o’clock meridian were directly sutured to internal scleral wall through scleral grooving wound at half superior quadrant.
After iris reattachment was finished, irrigation/aspiration performed to clean up viscoelastic residual.
Final step was suturing the gap of scleral grooving wound, then sutured the conjunctiva and lastly injected bubble to establish anterior chamber form.
Sebutkan permasalahan nya
One day post-operative, visual acuity was hand movement and IOP was 16 mmHg (iCare®). Cornea was edema with descemet fold, anterior chamber was deep with coagulum and fibrin, the iris was vaguely attach 360o to peripher and form pupil shape which irregular and fixed dilated. Lens status was aphakic and funduscopy was hard to be evaluated.
He was prescribed methylprednisolone 3 x 4 mg orally, prednisolone asetate and levofloxacin eye drop 6 x of the left eye.
Masalahnya apa?
Suggestion?
Two weeks post-operative, his visual acuity was still hand movement and IOP was 38 mmHg (iCare®). There were still conjunctival and ciliary injection, nylon sutures a 1 hour and 9 hour o’clock position, prolene suture at 2 hour o’clock position. Cornea was still edema with descemet fold. Anterior chamber was deep, coagulum at nasal and inferior was decreased, cells +1 and flare (+) (figure 5). He was managed by topical steroid and antibiotic eye drops.
He alsos controlled to Glaucoma division as diagnosed as secondary glaucoma post iridoplasty + ICCE of the left eye and managed by timolol maleate ED 2x, brinzolamide ED 3x, latanoprost ED 1x, acetazolamide 3 x 250 mg, and kalium aspartate 2 x 300 mg orally. If the IOP could not be controlled by medical treatment, Glaucoma Drainage Device (GDD) implantation supposed to be considered.
Kenapa minggu ke- 6 baru di konsul ke retina
Three weeks post-operative, his visual acuity could be corrected to 3/60 by S+10.00 spherical lens, his left eye IOP had been managed to 18 mmHg by antiglaucoma medications.
Corneal was still edema,
deep Anterior chamber, but no more coagulum was found.
There was still minimal iridodialysis at 7 hour o’clock position and 1 to 5 hour o’clock position.
We also consulted to Vitreoretina Division to find out whether any problems of posterior segment and determining the outcome probability if we plan to perform secondary IOL implantation to this patient.
after performing orbital ultrasound , Vitreoretinal division assessed this condition as vitreous hemorrhage of the left eye and planned to perform vitrectomy + endolaser with or without silicon oil implantation.
Six weeks post-operative his visual acuity was the same. The IOP was 24 mmHg (iCare®). There was still minimal iridodialysis at this meridian (fig.8). CRS division will perform secondary IOL implantation after posterior segment was well managed.
Direct impact- produces maximum damage at point of impact
Compression wave force – transmitted through fluid contents in all directions ,strikes angle of anterior chamber , pushes iris - lens diaphragm posteriorly and strikes retina and choroid – cause commotio retina
Reflected compression wave – after striking the outer coats , the compression waves are reflected towards posterior pole and foveal damage
Decompression wave force- after striking the posterior wall , it rebounds anteriorly. This damages retina choroid by forward pull and lens iris diaphragm by forward thrust from back
then the
Countre coup mechanism happened-
Bikin comparison dengan kasus
Ceritakan inervasi
Iris as the most anterior part of the uveal tract. It divides the anterior segment into anterior and posterior chambers. It is composed of blood vessels, connective tissue, muscles, melanocytes, and pigment cells.
The mobility of the iris allows the pupil to change size, this ability is related to one of its main function related to depth of field and depth of vision in one’s vision.
Iris is rich of blood vessels as it forms the bulk of the iris stroma with most follow a radial course that arise from the major arterial circle and passing to the center of the pupil.
The mechanism of trauma of this patient is possibly caused by the countre-coup mechanism. The impact energy from the front of the eye globe will be bounced back, this bounce energy pushes the lens anteriorly, which may be resulting damage to the zonules and the iris. Subtotal iridodialysis may result in disruption of aqueous humor outflow because of damage in the trabecular meshwork.
The iridodialysis involved more than the entire superior one half of the iris, also folded
Kasih penjelasan atau video
The oldest technique that used for iridodialysis repair is open system approach
Itis easier than the closed one, but this approach requires a large wound (more than 90o – 180o). This approach access the iridodialysis site through a limbal self-sealing incision or a scleral tunnel incision by making a full-thickness scleral incision at the iridodialysis quadrant. The iris edge is grasped with a forceps or iris hook, drawn to the internal scleral wall, then sutured to the sclera
McCannel is the most widely used technique, it involves the creation of a peritomy in the quadrant of the iridodialysis.
A suture with double armed needle is passed through a paracentesis site located 180° away from the iridodialysis. The needle is passed across the chamber, through the torn iris edge, and out through the sclera at the position of normal iris insertion. The needle exits beneath a large preplaced scleral flap. A second paracentesis site is then created just above the suture exit site (beneath the flap). An iris hook is then passed through this second entry site and used to retrieve the other end of the polypropylene suture. The suture is tied, buried, and the flap re-apposed
Best suture material for iridodialysis repair surgery is monofilament polypropylene. It has a smooth, snag-resistant, and resist degradation. Needle with tapered body does not cause further side cutting of the iris tissue when the needle passes through.
Our surgeon used a double-armed Pair-Pak needle (Alcon) polypropylene 10.0 suture with spatula cutting edge to repair the iridodialysis.
In our surgical technique…
The beginning in Our surgical technique is almost similar with the close chamber, cross-pupil technique
The first needle, the anterior chamber was entered at the main port which made at the oppositely from the dialysis site through the corneoscleral limbus, passed through the base of the iris, and exited through the chamber angle and sclera nasally.
The second needle entered the anterior chamber through the same entry site to the previous site as the needle exited
Then the suture was tied.
Modification was made when our surgeon penetrate to anterior chamber transcorneal oppositely to reattach the iridodialysis at temporal meridian. The knot also made on the outer sclera of iridodialysis site. (G)
Then to reattach the upper meridian iris, he used direct suturing to the internal sclera from scleral grooving wound incision. (H)
Most of
There is no iris atrophy, means this tissue is still viable. The viability of the iris which has been repaired in this report possibly because the iris vasculature has abundant blood flow. It has blood supply from the long posterior ciliary artery branches from the sclera toward the ciliary body to form a V-shape, travels to the inside of the iris, and forms major arterial circle of the iris near the iris root. From the major arterial circle of the iris, the iris artery travels to the pupillary margin at a constant interval.19 The iris is still anatomically attached at 8 and 4 o’clock hour meridian. So the supply from the long posterior ciliary artery is still possible.
Ocular contusion can cause disruption and trabecular meshwork leads to obstruction of aqueous flow
Tears in trabecular meshwork typically occur after contusions but often are not recognized because gonioscopy is not performed routinely.
Girkin et al30 reported that 35.8% of their patients with secondary glaucoma due to ocular trauma suffered angle recession and 58.3% had hyphema. The key finding is a previous tear in the ciliary muscle, called angle recession
Extension of endothelial layer with a descements – like membrane from the cornea over anterior chamber angle
Angle recession more than 180 degree generally cause rise in IOP.
Our patient had high IOP at his initial visit, and there were no significant hyphema findings on his ophthalmological status. Besides the iridodialysis, we found other his lens was hazy with subluxation. Traumatic cataract made his lens swollen, and injury to the zonules result in subluxation or dislocation of the lens. A swollen lens may cause a pupillary block or direct closure of angle structures. Anterior displacement of the lens also causes a pupillary block, which leading acute angle-closure glaucoma. Besides of the displacement, contusion also may cause true disruption of the lens capsule, and it could lead to the release of the lens particles into the anterior chamber, obstructing the aqueous outflow pathway.
It may cause excessive glare, photophobia, and monocular diplopia.
Comprehensive management is needed in managing this case.
We have to discuss and collaborate with other division such as glaucoma and vitreoretinal to decide How when and what kind of surgical management to be attempted to give the best outcome for this patient
