Prolene 10-0/ 9-0 sutures are used by the anterior segment surgeon in cases of :-

2. Prolene 10-0/ 9-0 sutures are used by the anterior segment surgeon in cases of:- • 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. • Internal fixation • Fixation of IOL to the iris, • Pupilloplasty (segmental or complete) in cases of loss of iris tissue, • Constriction of a permanently dilated pupil.

3. Scleral fixated IOL, Cionni’sring fixation in cases of zonular dialysis, Iridodialysis– fix the iris to scleral wall through pars plicata Scleral wall fixation.

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.

7. SFIOL(Scleral fixated IOL)

8. The prolene needle is brought out along with the 26 G needle. • Similarly the second arm of the needle is also brought out through the opposite scleral bed. • Hence , we have now two threads in the eye

9. The two threads are brought out through the main wound & cut in between

10. The SFIOL is positioned and the cut end of threads are tied at the eyelets of the SFIOL on both sides

11. The SFIOL is introduced in the AC

12. The SFIOL is positioned with slight traction on the threads

13. The sutures are tied to the scleral bed • The scleral flaps are sutured, one by one on both the sides. • Conjunctiva above is sutured .

14. Cionni’s ring fixation in cases of zonular dialysis

15. Superior Zonular dialysis can be appreciated

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’sbefore 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 irisalong 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.

19. iridodialysis

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. Iris fixation of IOL Pupilloplasty(segmental or complete) in cases of loss of iris tissue, Constriction of a permanently dilated pupil. Internal fixation

22. Iris Fixation of IOL

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.

29. Final position

30. A curved 9-0 needle is passed from the cornea and behind the iris haptic elevation, and re-emerges soon after. • The curved 9-0 needle now re-emerges from the cornea at a different site.

31. An instrument is used to hook the thread. (Siepsen’s Technique)

32. Now the thread is brought out from the initial wound

33. The threads are externalized and a double knot as shown is placed.

34. The threads are pulled so as to position the knot. • A similar knot is placed again by repeating the above steps. • The opposite haptic is similarly fixated.

35. pupilloplasty

36. Complete iridectomy closure • 26 G needle/cannula under the iris , • Prolene needle above the iris perforates the iris and enters the needle.

37. Second end of iris is engaged in prolene suture in the same way, hence both threads are now on the same side.

38. Knot is tied outside and slipped in

39. Dilated fixed pupil This 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.