Surgical Repair of Atonic Pupil with Iris Cerclage and Knot Internalization

Pupil restoration requires a stepwise temporal approach. For the right eye:

• 3 equidistant 1-mm corneal incisions at 3, 7, and 11 o'clock
• temporal keratome incision at 9 o'clock
• iris tissue recruitment with acetylcholine and centripetal stretch
• Visco-cohesive to maintain chamber
• double-armed 10-0 Prolene suture with entry of a curved long needle at 3 o'clock
• draping of iris onto needle tip along pupil edge, displacing it along its arc; needle exteriorization at 11 o'clock
• 2nd long needle entered at 3 o'clock, inferior pupil edge sutured similarly and exteriorized at 9 o'clock
• temporal pupil edge sutured and 2nd needle exteriorized at 11 o'clock
• both cut suture ends exteriorized at 9 o'clock
• knot initiated with 3 throws, rested on corneal surface at 9 o'clock, and internalized with micrograsper

Second and third single throws are conducted similarly, aiming for a final 3–4-mm pupil size to enable adequate retina viewing postop and resolve the patient's symptoms.