Arun Singh, MD, discusses a presentation on iris lesions he gave recently at the American Academy of Ophthalmology’s 2022 annual meeting in Chicago on the use of small incision garden hydroaspiration of iris lesions.
Note: This transcript has been lightly edited for clarity.
David Hutton, Ophthalmology Times: I'm David Hutton of Ophthalmology Times. Joining me today is Dr. Arun Singh. At the recent American Academy of Ophthalmology meeting, he discussed small incision garden hydroaspiration of Iris lesions. Thank you for joining us today. Dr. Singh. Tell us about this topic.
Arun Singh, MD: Well, thank you for having me. I was lesions are tumors are common, many are benign. Many very small, with patients of walking around without any symptoms and then they go for routine eye exams, contact fitting, etc. They're seen by the optometrists or primary care physician and noted to have something on the iris. At this point, the vision is 20/20, they have no complaints.
And suddenly, they're now sent over to an expert or a specialist to say you may have a tumor and you need an assessment. So that's a unique challenge. Already, patients have no complaints, they have a normal acuity and then you're starting to talk about a serious or important consequential diagnosis.
And then you say, with the exam history, which is usually not much, you do the exam, and in the iris, there is very limited imaging that we can do, we can do UBM, we can take a photograph, we can do OCT, but that's about it. We don't have any other imaging that guides us to the to the diagnosis, most of it is just by looking at it by a slit lamp exam.
And after you've done all that, you make some kind of a diagnosis and say, “Oh, this is very likely a benign growth, this could be melanoma, this could be a tumor. And based on those diagnosis and the size and location of the lesion of the tumor, we start to think about how we can approach it.
So. if it's benign, you say, oh, I can just observe it, I've taken a photograph and ultrasound and the following. But if it's a little bit more serious, you end up then thinking of maybe I need to biopsy this.
And that's where it takes us into surgical approaches for managing these tumors that are small, could be partly in the ciliary body, for example, not all visible, or they may be even vascular.
And they start to think of oh, I need to biopsy, I can do a needle biopsy, putting a very fine needle into the tumor. Or you could do an excisional biopsy if it's small enough. If it's really big, you can think of an incision biopsy, which is usually not done because that can cause spillage of tumor.
So you're basically left with either a needle biopsy or excising the tumor. And so this technique that you just mentioned, small incision surgery is a take on that kind of approach of excision where you the intent is to remove whatever tumor you have completely.
Compared to what we have done in the past, we would do kind of big incision at the limbus, lift the cornea, go and cut the iris out and take the tumor that you can imagine will cause astigmatism, longtime for healing issues with sutures, etc.
And here the approach is more along the lines of what we take laparoscopy. You kind of make multiple decisions, but they are small each one is one two millimeters and the largest one where we say three, three and a half centimeters. But yeah, many of those. And you work with instruments in the anterior chamber, after deepening it with viscoelastic and you cut the iris. So that's not that complicated, and can be achieved with using proper instruments.
More important in this concept is to then remove the tumor from the small incision without seeding the wound itself, because they can be potentially malignant. And if you tried to drag it out of the anterior chamber, you could seed the edges of the wound and cause dissemination of the tumor. So we therefore put a tube in again, which has full viscoelastic and aspirate the tumor into the tube. So that's the hydroaspiration part of it. And then you withdraw the tube. So you have a small incision, and then you're guarded regarding the wound from dissemination, and you are aspirating the tumor into the to the iris kind of folds over a little bit like a taco almost and gets sucked into the tube. And you can take the tube out. So that's the kind of the technique and important components.
Then you suture some of the bigger wounds, which may require two or three nylon sutures. The smaller ones, you don't have to do anything. And if the iris defect is not large, you can do pupilloplasty. There are techniques to use sutures to close that, and you take out this tumor.
The last part, which is I think very important here ,is handling of this tumor sample or the iris tissue, which is very fragile, very delicate. The moment you touch it with forceps, it just breaks into pieces. So we really don't want to touch the sample directly by instruments because we are interested in assessment of tumor margins, I want to make sure that this tumor was removed completely, and the margins around them are negative. If you fiddle around with the sample, it breaks fragile. The pathologist can never comment on whether the tumor was removed completely.
So in oncology this, this is a very important aspect of all of it. Because patients, the first thing they ask is, did you get everything out? And if you can't tell that, then it's very embarrassing, let's say.
So for us, we then take this tube that the sample is already in the tube, and we express that onto a filter paper. The sample will go on to the filter paper and flat, imagine like a pizza slice, it will flatten out. And then you take the filter paper and put it on to the formalin and fixated. So the tumor sample isn't bent margin is not distorted.
We get a good reliable pathology to say, well, whatever it was, and the margins were negative or involved, hopefully negative. That's what you're aiming for. So that's the important components of the whole technique. And I think, to me, it overcomes some of the issues that made us hesitate to operate on tumors.
You see the tumors and say it is going to be a complicated surgery and it is going to take a long time to heal. If you can get away with less risk, then you are more likely to do it. And that is what we are noticing in our own practices.