EyeWorld Asia-Pacific December 2014 Issue

14 December 2014 EWAP FEATURE still work from an optic perspective whether the pupil is widely opened, whether it’s fixed at a particular diameter, or whether it’s completely normal,” she said, but cautioned that managing patient expectations is essential. After implanting a toric lens in these patients, Dr. Gupta removes the OVD from behind the lens and rotates it “to within about 20–30 degrees of where my final axis of placement is going to be,” removes more OVD, and rotates the lens a bit closer to the final axis. “When the lens is within 5 degrees, I will take out the Malyugin ring and fine-tune the IOL placement,” she said. “The pupil will often stay a little bit stretched after you take the Malyugin ring out.” She advised retaining some of the OVD in the chamber when removing the ring “so there’s less damage to the endothelium.” But if the pupil does come down or if visualization is difficult, she takes a Kuglen hook (Katena, Denville, NJ, U.S.) and “essentially tents the iris far enough into the periphery so that I can see the exact alignment of the lens.” She puts “some gentle downward pressure on the lens so it doesn’t rotate” as she removes the remaining OVD. Alpha-blockers and cataract surgery Alpha-blockers—and tamsulosin in particular—are well-known causes of IFIS. None of the physicians recommended that patients stop their medication use before cataract surgery simply because the patient “can run into bladder issues during the case if they’re on tamsulosin for benign prostatic hyperplasia,” Dr. Summerfield said. “Discontinuing the medication could make the condition worse, and it’s not going to help with the floppy iris.” Because there are numerous drugs that can treat prostate disorders, Dr. Summerfield has broadened his questioning to ask if patients “have any prostate hypertrophy or if they have any bladder issues at all, for women.” Dr. Gupta cited a case recently where a woman on finasteride and doxazosin developed IFIS; although these drugs are often used as prostate medications, the patient was using it to treat alopecia and hypertension. Some blood pressure medications are in the same alpha- blocker family as tamsulosin, and Dr. Gupta expects more women will develop IFIS than may be expected. “By asking open-ended questions about any drug use for prostate issues, you’re able to discover that patients may have had a history of using tamsulosin in the past, or related medications. Even saw palmetto, with enough chronic use, can cause significant IFIS,” Dr. Green said. “Tamsulosin is the worst offender, but alfuzosin can wreak havoc as well.” Dr. Gupta is particularly wary when patients have light-colored irises and use alpha-blockers. “In these cases, I always use ‘Shugarcaine’ (lidocaine/ epinephrine solution) to manage the potential complications better,” she said. Views from Asia-Paci c YAO Ke, MD Professor, Eye Institute of Zhejiang University Eye Center, Second Af liated Hospital of Zhejiang University, College of Medicine 88 Jiefang Road, Hangzhou, 310009, China Tel./Fax no. +86-571-87783897 xlren@zju.edu.cn I n cataract surgery, a small pupil is a complex case for the surgeon. I agree with the expert’s view that the use of hooks or rings is effective in this case. Generally, I use iris hooks in patients with pupils that are smaller than 4 mm. The corneal incision is usually made at 12 o’clock and the sideport incision made at around 3 o’clock. Then iris hooks are inserted through the other four stab incisions at 1:30, 4:30, 7:30 and 10:30 to make it fully exposed to the surgical eld. In order to keep the pupils regular postoperatively, I rst make the hooks grapple the iris, and then stretch it very slowly. According to my experience, a majority of the pupils were round after surgery, except for atrophic ones in uveitis cases. On the subject of toric lens’s application in small pupils, my attitude is not as positive as that of the experts. In my opinion, toric lenses may not be chosen for the patient if small pupils are found before lens implantation either preoperatively or intraoperatively because to check lens position is relatively dif cult. However, in very few cases, the pupils become smaller after toric lens implantation, and in order to ensure the lens position, I sometimes use the iris hooks to make the lens markers clearer and remove the hooks after removing OVD and water-tightening of incision. IFIS is well known as one of the causes of intraoperative small pupils. Besides alpha-blockers and other reasons mentioned in this article, in a recent study we found that Reserpine, Clozapine, and post-panretinal phacocoagulation are also risk factors for IFIS, and the incidence rate of IFIS is 3.18% in the Chinese mainland. Retained lens fragments are considered to be a depressing situation for most surgeons. In my opinion, the Venturi-based phaco machine can make a big ow of irrigation/aspiration, such as the Stellaris (B+L), so that it allows the surgeon to notice the retained lens fragments more easily. In addition, before the closure of incision, I normally put the I/A tip on the IOL’s surface to aspirate the possible hidden lens fragments. These methods can avoid the lens fragments hiding behind the iris. Editors’ note: Dr. Yao has no nancial interests related to his comments. Cataract - from page 13