EyeWorld Asia-Pacific September 2014 Issue

30 EWAP CATARACT/IOL September 2014 by Tony Realini, MD, MPH Intraoperative pupil expansion: Making challenging cases easier Addressing controllable factors, minimizing chance P inpoint pupils, zonular weakness, small eyes—these and other features virtually guarantee a non-routine case. Some adrenaline junkies thrive on the most complicated, technically challenging cataract surgeries imaginable. Most surgeons, however, strive to make every case as routine as possible. This requires actively addressing the factors that can be controlled and minimizing what is left to chance. The dreaded small pupil Small pupils are a common occurrence in a busy cataract practice. A poorly dilated pupil can set the tone for the entire procedure; without adequate visibility, every step is made more challenging than it needs to be. Fortunately, this is an issue that can be identified and planned for during the preoperative assessment, and there are several options available for expanding the stubborn pupil. Simple viscodilation works for many eyes. Iris retraction hooks have been around for decades and are quite effective. More recently, the Malyugin ring (MicroSurgical Technologies, Redmond, Wash., U.S.) has become available. Each of these options has its advantages and disadvantages. “Poor pupil dilation has been shown to increase the risk of complications during cataract surgery,” said Jonathan Fay, MD , Albert Einstein College of Medicine, New York, NY, U.S. Albert Khouri, MD , Rutgers University, Newark, NJ, U.S., agreed. “Complications associated with small pupils during cataract surgery include capsule rupture and vitreous loss,” he said. “Pupil enlargement techniques such as iris retraction and pupil stretch techniques can facilitate intraoperative visualization and prevent complications.” The way we handle the small pupil can also cause problems. “Pupil manipulation during cataract surgery may lead to pigment dispersion with subsequent inflammation and intraocular pressure (IOP) elevation,” said Dr. Fay. Malyugin ring safety Dr. Fay recently conducted a retrospective study to evaluate the course of postoperative inflammation and IOP control in eyes undergoing cataract surgery with and without the use of a Malyugin ring. He and his colleagues reviewed the medical records of 20 consecutive cases utilizing the Malyugin ring and compared the outcomes to a control group of 21 age- and gender-matched cases all performed by the same surgeon. On the first postoperative day, mean IOP was similar between groups, he said. “In the Malyugin ring group, there was one patient who experienced an IOP spike of 30 mmHg or more, compared to two patients with similar IOP spikes in the control group,” he added. Uncorrected visual acuity was substantially lower on the first postoperative day in the Malyugin ring group compared to the controls. “The control group gained an average of 0.4 lines of Snellen acuity by the first day, compared with an average loss of 1.3 lines in the Malyugin ring group,” he said. This is likely not attributable to the use of the ring but rather to the fact that it was Mean difference of best corrected visual acuity at all time points for Malyugin ring (green) and iris hooks (blue) Source: Albert Khouri, MD continued on page 32