techniques
Small incision single-suture-Ioop
pupilloplasty for postoperative atonic pupil
Anders Behndig, MD
ostoperative atonic pupil is a complication of many
P types of anterior segment surgery. In a survey of
members of the American Society of Cataract and
Refractive Surgery, 1 60% of respondents had seen at
least 1 case of atonic pupil after cataract surgery in the
past 5 years, with a total of 1543 cases reported. The
complication has also been reported after intracapsular
cataract extraction2 and keratoplasty for keratoconus. 3
An incidence of 2.29% after extracapsular cataract
extraction, 1.10% after phacoemulsification, 4 and 5%
after penetrating keratoplasty5 has also been reported.
The exact mechanisms of atonic pupil are unknown;
iris ischemia resulting from a postoperative rise in
intraocular pressure (IOP)6 or strangulation of iris
vessels mechanically5 or from viscoelastic substances7
have been proposed as possible causes.
From the Department of Ophthalmology, Norrlands University Hospi-
tal, Umerl, Sweden.
Supported in part by a grant from Carmen and Bertil Regner's Fund.
The author has no financial interest in any product mentioned
Reprint requests to Anders Behndig, MD, Department of Ophthalmol-
ogy, Norrlands University Hospital, Umerl. S-901 85, Sweden.
J CATARACT REFRACT SURG-VO L 24. NOVEMBER 1998
Atonic pupil is often irreversible1.5 and will not
respond to pharmacological treatment. 8 No specific
treatment is necessary for mild symptoms; however,
some patients experience glare or other visual distur-
bances severe enough to necessitate the use of a Narcis-
sus contact lens or surgical correction. 1•8 I describe a
new small incision technique to correct the atonic
pupil.
Surgical Technique
Local anesthesia such as peribulbar or sub-Tenon's
flush (possibly intracameral lidocaine) can be used.
Topical anesthesia is probably insufficient because some
iris traction is necessary. A temporal approach is prefer-
able, especially in deeply positioned eyes.
1. Three 1.0 mm limbal or clear corneal stab
incisions are made at 9,5, and 1 o'clock (termed 11,12,
and 13, respectively). (The example is from a right eye.)
2. The anterior chamber is filled with viscoelastic
material.
3. A PC7 needle on a 10-0 polypropylene suture
(Alcon Laboratories) is gently inserted through 11. Care
is taken to place the needle through the lllC1SIOn
without capturing corneal tissue (Figure O.
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 TECHNIQUES: BEHNDIG
Figure 1. (8ehndig) The PC? needle on a 10-0 polypropylene
suture is placed through 11.
4. A forceps usually used to peel epiretinal mem-
branes (Grieshaber 612.03) is inserted through 13.
5. The iris is grasped with the forceps at 10 o'clock
and pulled centrally, allowing the long, slightly bent
PC7 needle to place a suture just outside the pupil
border (Figure 2). This is repeated, making a continu-
ous row of 3 to 4 sutures in the lower temporal part of
the iris toward 12.
6. The forceps is withdrawn.
7. The needle tip is inserted into the tip of a blunt
flush cannula placed through 12 (Figure 3). This allows
the tip of the needle to exit through 12 with no risk of
capturing corneal tissue. The needle is pulled out
through 12.
8. Steps 3 through 7 are repeated to make a
continuous suture loop from 12 to 13 and then from 13
to II (Figure 4).
Figure 3. (8ehndig) The needle tip is inserted through a can-
nula, which is placed through 12.
1430 J CATARACT REFRACT SURG-VOL 24, NOVEMBER 1998
Figure 2. (8ehndig) The suture is placed just outside the pupil
border.
9. The ends of the suture, now coming out of 11,
are tied, and the pupil size is adjusted using appropriate
loop tension. The knot is placed in the anterior cham-
ber and the viscoelastic material removed (Figure 5).
Case Report
A 40-year-old man had phacoemulsification and
intraocular lens (lOL) implantation in the left eye in
1996. One day after surgery, lOP was 56 mm Hg,
probably because of insufficient removal of the visco-
elastic material. This was treated conservatively with
acetazolamide. The pupil was 7.5 mm and atonic at
1 month. Pilocarpine was tried but had no effect. The
patient had severe glare and monocular diplopia from
light entering the pupil below the 10L edge. A contact
lens was suggested, but the patient declined.
After almost 1 year, there was no change. Pupil-
Figure 4. (8ehndig) The suturing steps are repeated to make a
continuous loop.
 TECHNIQUES: BEHNDlG
Figure 5. (Behndig) The ends of the suture are tied, and the
pupil is adjusted by tension on the loop_
loplasty was performed as described above. One day
later, visual acuity was 20/25 (the same as preopera-
tively), the diplopia had resolved, and the pupil was
4.0 mm, although somewhat irregular. At 1 month, the
patient was content with the result and had no glare.
Refraction was unaltered, and no astigmatism was
induced.
Discussion
Although 42% of patients with atonic pupil after
intraocular surgery are asymptomatic l and will require
no specific treatment, surgical correction may be the
only acceptable option in some cases. The lack of a
simple, safe surgical technique may have resulted in an
unnecessarily conservative approach to this condition.
Large incision purse-string techniques have been tried
but are difficult, even risky. 9A closed-system technique,
described by Pius Bucher, MD, and modified by
Osher,9 involves using a straight needle to suture and
compress each of the 4 iris quadrants separately. Ma-
neuvering a straight needle inside the anterior chamber
is a demanding task, however, and incision placement is
crucial for success.
The slightly bent PC7 needle works more smoothly.
When the iris is gently pulled with a peeling forceps,
the needle can take a straight course with little maneu-
vering. Surgery of this type is always irreversible, but
because the method should permit more predictable
regulation of postoperative pupil size, the pupil can be
] CATARACT REFRACT SURG-VOL 24, NOVEMBER 1998
left sufficiently large to allow later vitreoretinal surgery
or laser treatment. Moreover, the suture is readily
visible at the pupil border with this method and in case
of an emergency, one should be able to cut it with a
neodymium:YAG laser and enlarge the pupil in the
usual way as atonic pupils respond to mydriatics. 9 A
possible disadvantage may be the risk of capturing
corneal tissue with the needle; however, the precautions
mentioned should minimize this risk.
An additional indication for this technique may be
the common combination of traumatic mydriasis and
traumatic cataract. This procedure should be suitable
combined with cataract surgery or as a separate second-
ary procedure.
I believe this small incision technique provides a
reasonably simple and safe way to correct a large pupil
in these conditions with minimal induced astigmatism
and surgical trauma. This makes it suitable for patients
suffering from glare or other visual disturbance caused
by an atonic pupil.
References
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cataract surgery. 1 Cataract Refract Surg 1995; 21:170-
175
2. Percival SPB. Results after intracapsular extraction: the
atonic pupil. Ophthalmic Surg 1977; 8(3):138-143
3. Urrets-ZavaHa A lr. Fixed, dilated pupil, iris atrophy and
secondary glaucoma; a distinct clinical entity following
penetrating keratoplasty in keratoconus. Am 1 Oph-
thai mol 1963; 56:257-265
4. Halpern BL, Pavilack MA, Gallagher SP. The incidence
of atonic pupil following cataract surgery. Arch Ophthal-
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