EyeWorld Asia-Pacific September 2013 Issue

10 September 2013 EWAP FEAturE Views from Asia-Pacific Boris MALYUGIN, MD, PhD Professor of Ophthalmology, Deputy Director General (R&D, Edu), S. Fyodorov Eye Microsurgery Complex State Institution Beskudnikovsky Blvd 59 A, Moscow, 127486, Russian Federation Tel. no. +7(499)488-8511 Fax no. +7(499)905-8051 boris.malyugin@gmail.com T here are different ways to handle the Malyugin Ring. But many times surgeons ask me about my personal approach in dealing with the device. Here below I describe some useful tips and tricks that are very helpful in my clinical practice. Implantation of the Malyugin Ring: • Operating under topical – inject lidocaine intracamerally (to avoid the sensations of the patient during the iris tissue manipulations), followed by phenylephrine 1.5% (to enhance pupil dilation and strengthen the rigidity of the iris tissue by contracting the dilation muscle). • Do not overfill the AC with OVD, the latter will cause closer apposition of the iris to the lens capsule and will make engagement of the pupil edge more difficult. • Insert the injector and position its tip very close to the iris margin. • Push on the thumb button and engage the pupil edge with the distal scroll. • Continuing to push on the thumb button, slowly withdraw the inserter while expelling the ring. • Usually two side scrolls are engaged with the pupil margin automatically. In more rare cases when the pupil is too small or the anterior lens surface is overly prolate, it is hard to engage both lateral scrolls while injecting the ring. You can help yourself with the sideport instrument (Osher/Malyugin Ring Manipulator, Lester or Kuglen hook). Avoid using the Sinskey hook because there is an increased risk of puncturing the anterior capsule with its tip. • To disengage the proximal scroll from the injector hook, use the sideport instrument and displace the ring away from the incision or to the side (counterclockwise). • Retract the injector hook by pushing on the thumb button backwards, becareful by not catching the proximal scroll again. Removal of the Malyugin Ring: • With the sideport instrument, disengage the distal scroll from the iris first and displace the whole ring slightly away from the main incision, then disengage the contralateral (proximal) scroll. • Insert the injector into the AC and push on the thumb button all the way forward. • Position the injector tip footplate under the proximal scroll and engage it with the injector hook by pressing on the thumb button backward. • Start retracting the ring. When both lateral scrolls will join together press on the upper one from above with the sideport instrument to help them both entering the injector tube. • Retract the injector from the eye. Editors’ note: Dr. Malyugin has financial interests in the Malyugin ring. Malyugin ring preferable to traditional iris hooks for typical small pupil cataract cases. Such hooks are good if a large 3-mm incision isn’t otherwise required. “When you’ve already got a cataract incision I think the Malyugin ring is very good,” Dr. Culbertson said. For preventing pupils from constricting during an IFIS cataract case, he thinks the ring is extremely effective. “It raises the cost of the case in the [US]$100 range, but it’s easy to put in and easy to remove,” Dr. Culbertson said. “It gives you 7 mm of viewable area, which is quite adequate.” During the IFIS case it stabilizes the pupil in the right position and prevents it from flopping, he said. Studying up on pharmacology Dilating drops have a role in cataract cases involving small pupils. If the pupil constricts during the case, it may be that the patient received inadequate dilating drops initially or that it has been too long since the patient received drops. In such cases, practitioners can use intraocular solutions to expand the pupil, Dr. Culbertson said. Bisulfate-free epinephrine is one possibility. The other is intraocular lidocaine, dubbed Shugarcaine after deceased practitioner Joel Shugar, MD . It’s possible to use these together in another solution, epi-Shugarcaine. “The lidocaine can cause the pupil to dilate, Big - from page 9