2 Prolene 10-0/ 9-0 sutures are used by the anterior segment surgeon in cases of:- Scleral wall fixationScleral fixated IOL,Cionni’s ring fixation in cases of zonular dialysis,Iridodialysis – fix the iris to scleral wall through pars plicata.Internal fixationFixation of IOL to the iris,Pupilloplasty (segmental or complete) in cases of loss of iris tissue,Constriction of a permanently dilated pupil.
3 Cionni’s ring fixation in cases of zonular dialysis, Scleral wall fixation .Scleral fixated IOL,Cionni’s ring fixation in cases of zonular dialysis,Iridodialysis – fix the iris to scleral wall through pars plicata
4 LIMBUS BASED SCLERAL POCKET Instead of making flaps we can make scleral pockets (limbal based pocket), of the same size as we make for phacoemulsification. The advantage of this technique is that scleral flap closure is not required at the end of surgery. Conjunctiva is detached & limbus based scleral pocket is created.
5 FORNIX BASED SCLERAL POCKET Straight 3 mm incisions are given 180º apart at the limbus, without removing the conjunctiva.2.5 mm deep pocket is made towards the sclera, making fornix based scleral pocket,As the direction of the pocket is opposite to the direction of the needle, it is not possible to insert the needle directly at the base underneath the flap. The needle perforates the conjunctivoscleral upper flap and scleral base to enter the eye.The threads are passed and tied into the IOL. Then these threads are pulled out from the scleral pocket by sinskey hook for tying and burying the knot in the pocket.This is a little more complicated , with more chances of bleeding , but still a greater technique to master as it is faster and requires no cautery and suturing of conjunctiva or scleral flap
6 2 points are marked 180º apart, fornix based conjunctival flap are raised and light cautery is applied.Limbus based partial thickness scleral flaps are raised, 2.5X 3 MM and 500µ in depth.At 1.5 mm from the limbus, through the scleral bed a 26G needle is passed from one side and a straight needle 9-0 needle from the other side, which is loaded into the barrel of the 26G needle in the center of the eye.
16 Cionni’s ring needs fixation at only one point most of the time, so we need only one scleral flap at the site of maximum zonular dialysis.Prolene threads are fixed to the eyelet of cionni’s before inserting the cionnis into the capsular fornices.The loop of cionni’s which fixates it to the sclera , comes out of the rhexis margin and lies outside the capsule and underneath the iris along with prolene traction sutures
17 Needle is brought out through the scleral pocket, using the same technique as in scleral fixated IOL
18 After inserting the IOL , traction is applied along the sutures , which is tied at the scleral bed to get the best possible centration of the IOL.Tenting of the rhexis margin due to traction can be appreciated.
20 Scleral pocket is created and 26 G needle is passed & kept under the edge of the dialysed peripheral iris.Prolene needle comes from the top of the iris and perforates it and enters the 26G needle and then comes out of the eye.Procedure is repeated with second needle. Both these threads are tied which pulls the dialysed iris up.
21 Internal fixation Iris fixation of IOL Pupilloplasty (segmental or complete) in cases of loss of iris tissue,Constriction of a permanently dilated pupil.
23 The IOL is positioned such as the optic is above the iris plane and the haptics are behind the iris. A Rounded Repositor is used to elevate the optic so as the haptics can be appreciated better behind the iris
24 Railroad technique – 9-0 straight needle is passed from the cornea going beneath the iris and haptic elevation and re-emerging from the iris soon after.26G needle is inserted from the opposite site, and the prolene needle is loaded into its barrel and is brought out of the eye.
25 Now the prolene needle is reinserted through the same wound from which it was externalized. 26G needle is now inserted from the opposite site and again the prolene is loaded into its barrel.This complex is above the iris haptic elevation.
26 Both threads are externalized from the same wound
27 A knot is given and an instrument is introduced from the opposite side , so as to slide the knot to the appropriate position.
28 The knot is finalized and the threads cut. Similar procedure is repeated on the opposite haptic.
39 Dilated fixed pupilThis can be constricted but constriction is permanent, if there is sectorial dilatation then constriction is done as we do complete iridectomy closure
40 Multiple incisions are made and curved 26G needle is placed underneath the iris and a needle is passed through the adjacent incision. The prolene needle perforates the iris and enters the 26 G needle
41 Similar procedure is repeated through the multiple incisions
42 Traction is applied to the sutures so as to constrict the pupil and a knot is tied , which is slipped in.