EyeWorld Asia-Pacific December 2017 Issue

“I like to get the distal (usually nasal) loop first because some- times that loop will slide under- neath the iris rather than on top of it. It is much easier to retrieve from across the eye than from the subincisional area,” he said. “I then slide the manipulator under a loop and pull it out through the main incision. By moving my hand to the right as I take the ring in, the loops will slide out one at a time. For me, this has been more efficient than using the ring injec- tor to remove the device.” “To remove the ring, I first disengage the distal scroll and then disengage the proximal scroll and deliver it from the anterior chamber through the wound,” Dr. Weber said of his technique. “De- livering the scroll in this way al- lows for simple grasping with the inserter and complete withdrawal from the eye.” Dr. Crandall said he always uses the 6.25-mm ring, finding it gives him enough room to work while being easier to insert than the 7-mm size. He’ll use the latter if he’s concerned about the pupil coming down during surgery. Similarly, Dr. Weber said he’ll use the larger ring in cases with higher degrees of IFIS. If he decides to use hooks, Dr. Crandall makes his paracentesis just large enough and perpendicu- lar to the peripheral cornea so the hooks are pointed downward into the anterior chamber. If these are made parallel to the iris, they would tent it up, making every- thing else more difficult. “I place each of the hooks I’m using into the incisions and just catch the edge of the iris,” Dr. Crandall said, noting that he uses a square pattern. “Once all of the hooks are in, I’ll tighten each one to get the pupil size I want. I avoid over tightening these to minimize trauma to the iris sphincter; I get the pupil large enough for me to comfortably proceed with the rest of the case. “If I am dealing with a very floppy iris and iris prolapse, then I will also place a hook subincision- ally,” he added. To remove, Dr. Crandall said he’ll loosen them enough to dis- engage from the iris. Then he will turn the hook sideways and pull it out through the paracentesis. Dr. Weber said it’s important to have phaco settings available for IFIS or know what changes to make in fluidics for these cases. “It is fairly rare for me to use a ring or hooks thanks to smart fluidics and lidocaine with epi- nephrine,” Dr. Weber said. “Don’t be afraid to change tactics and use the multiple tools at our dispos- al—change out a ring for hooks, if necessary, and don’t forget about that fifth hook.” EWAP References 1. Ratra V, et al. Small pupil – big problem: A management algorithm. Asia Pac J Ophthalmol (Phila). 2015;4:131–3. 2. Hovanesian JA, et al. Intracameral phenylephrine and ketorolac during cataract surgery to maintain intraoperative mydriasis and reduce postoperative ocular pain: Integrated results from 2 pivotal phase 3 studies. J Cataract Refract Surg . 2015;41:2060–8. Editors’ note: Dr. Crandall and Dr. Weber have no financial interests related to their comments. Contact information Crandall: dackakarot@hotmail.com Weber: charles.weber@gmail.com 60 EWAP CATARACT/IOL December 2017 Cornea Ed Ad 1/2 vertical The basics – from page 59 Watch, Learn, and Share! Video Ed Watch, Learn, and Share! Available on mobile devices, tablets, and desktops On demand! Clinical presentations recorded live at Cornea Day 2017 in Los Angeles Watch for our weekly emails every Saturday, broadcasting recorded live cornea presentations All content is archived for future reference Video Ed .CorneaSociety.org Copyright ©2017 Cornea Society. All rights reserved. Learn from the cornea experts! Scan to view video using EyeWorld AR app