EyeWorld Asia-Pacific December 2016 Issue

December 2016 22 EWAP FEATURE Before and after insertion of a Malyugin ring. The concentration of the phenylephrine/ lidocaine combination Dr. Greenwood uses is phenylephrine 1.5%/lidocaine 1.0%. Both are preservative- and bisulfite-free. Source: Michael Greenwood, MD similar drugs that patients may use. Surgeons advise assessing for possible risks of IFIS early on, in the preop period. Dr. Condon will ask patients if they have had any treatment for a prostate condition. “Simply asking if they are taking tamsulosin is inadequate in terms of getting the full story,” he said, because there are other drugs that cause the same effect. He will also ask female patients if they have used drugs from the same class. In addition to prescription medications, over-the- counter herbs such as saw palmetto can cause IFIS issues, Dr. Condon said. Dr. Samuelson makes sure to let patients who have exfoliation- related glaucoma or who use tamsulosin know that they have a greater risk for surgical complications, albeit a small risk. Intraoperative management The surgeons interviewed by EyeWorld take special steps to manage cataract surgery in patients affected by IFIS. Dr. Condon pre-treats the eye with a mixture of 0.025% epinephrine and 0.75% lidocaine in fortified balanced salt solution—a combination called Shugarcaine after the late Joel Shugar, MD, who devised the mix. The mixture is made in the OR in advance of surgery; the lidocaine relaxes the sphincter and the epinephrine stimulates the dilator muscle. If that does not work effectively, Dr. Condon adds a mechanical device. “If you’re faced with a concerning case of potential IFIS, there is nothing more effective than a Malyugin ring,” he said. Although there are other devices from which surgeons may choose, Dr. Condon favors the Malyugin ring because it can go in through the operating incision versus having to make four incisions. Some surgeons may be reluctant to use the Malyugin ring because they don’t know how to properly insert it. Dr. Condon recommends practicing on patients who don’t really need it, so you feel ready when you do actually require it. Dr. Condon uses the Malyugin ring toward the beginning of a potential IFIS case but will use hooks if he is running into IFIS issues toward the middle of a case. For his surgical management, Dr. Greenwood uses preoperative pledgets with 10% phenylephrine, 1% tropicamide, 2% cyclogyl, and a nonsteroidal anti-inflammatory drug (NSAID). “Using the NSAID ahead of time stabilizes the iris more,” Dr. Greenwood said. If the patient has decent dilation, Dr. Greenwood uses a dispersive ophthalmic viscosurgical device (OVD) to complete the capsulorhexis. Next, he will inject a mix of 1.5% phenylephrine and 1% lidocaine if necessary. “Then I use the Malyugin ring if I’m not able to get them adequately dilated with the phenyl/ lido mix and the viscoelastic,” he said. Dr. Greenwood estimates that 10% to 20% of his IFIS cases require use of the Malyugin ring. Dr. Greenwood recommends surgeons have a low threshold for the use of mixes like phenyl/lido or a Malyugin ring. “When thinking about if you should use it, if it crosses your mind, the answer is yes. I’ve never regretted putting a device in the eye, but there’s always a time when you wish you put one in and you didn’t,” he said. Dr. Samuelson has a low threshold for using pupil expanders if a patient is at risk for IFIS. He also uses lidocaine with epinephrine, especially when there are other risk factors, such as exfoliation syndrome or a particularly dense lens nucleus. As a glaucoma surgeon, he does a good deal of cataract surgery in patients who have exfoliation syndrome. “In general, I simply tolerate moderately small pupils or use expanders only if it is 4 mm or less,” he said. Management of small pupil- related IFIS does not require any change in IOL use. These surgeons said the IOL selection process continues as normal. EWAP Editors’ note: The physicians have no financial interests related to their comments. Contact information Condon: garrycondon@gmail.com Greenwood : Michael.greenwood@vancethompsonvision.com Samuelson : twsamuelson@mneye.com Managing - from page 21