EyeWorld Asia-Pacific December 2016 Issue

December 2016 EWAP FEATURE 21 Managing IFIS and small pupils by Vanessa Caceres EyeWorld Contributing Writer Cataract surgeons advise careful step-by-step evaluation for fewer complications C ataract surgeons must continue to effectively tackle the risk for intraoperative floppy iris syndrome (IFIS) and the small pupils that can accompany it. “IFIS related to the systemic AT A GLANCE • Patients who have used tamsulosin or similar alpha-1 antagonists may experience IFIS during cataract surgery. • Ask patients preoperatively about their use of tamsulosin or similar medications, as well as the herb saw palmetto. • Special dilating mixes can assist with dilation in eyes at risk for IFIS. • Use devices like the Malyugin ring or iris hooks as necessary. Before insertion of a Malyugin ring After insertion of a Malyugin ring Source (both): Boris Malyugin, MD use of tamsulosin presents some unique pupil-related management problems for the phaco surgeon,” said Thomas Samuelson, MD , attending surgeon and co-founder, Minnesota Eye Consultants, Minneapolis. “One of the features of IFIS is that it can be a wolf in sheep’s clothing. That is, you may start the case with a perfectly normal-sized pupil or close to it. However, during the case, it becomes apparent that the iris tone is reduced, and there’s a significant tendency for iris prolapse. Once that process begins, the pupil often becomes less dilated and quite often much smaller than when the case first started.” With small pupils caused by other conditions, surgeons know in advance that hooks or rings will be needed. In a patient who has used tamsulosin or other similar medications, “you may need to change the plan and insert pupil expanding devices on the fly, after the phaco has started,” Dr. Samuelson said. Surgery in these eyes can take longer and be more challenging, said Michael Greenwood, MD , Vance Thompson Vision, Fargo, North Dakota. The cascade effects from IFIS, including the increased risk for iris damage, can lead to awful outcomes, said Garry Condon, MD , chair, Department of Ophthalmology, Allegheny General Hospital, Pittsburgh. Tamsulosin is the most widely prescribed alpha-1 antagonist for benign prostate hyperplasia in North America, but there are other Tips for better Malyugin ring management • When inserting the ring in the eye, engage the scroll farthest away from you first and then the two side ones. • Recenter the device so when you make the rhexis, it’s centered on the patient’s visual axis. • Use a second instrument to remove the ring, such as the Malyugin manipulator. Unhook the distal side first, and work your way around in a circle. Be careful not to take any iris tissue. • You can also grasp the ring with any type of forceps or the manipulator. However, make sure it doesn’t get caught on any tissue inside the eye as you bring it to the outside. Do this step before you remove the OVD. Source: Michael Greenwood, MD continued on page 22