EyeWorld Asia-Pacific December 2019 Issue

FEATURE 10 EWAP DECEMBER 2019 W hen dealing with the “unruly iris,” surgeons can employ a variety of tools. Cathleen McCabe, MD, Blake Williamson, MD, and Ashvin Agarwal, MD, discussed their preferences in terms of pharmacologic options vs. mechanical iris expansion devices and shared tips for addressing IFIS and iris prolapse. Pharmacologic options vs. mechanical iris expansion devices Dr. McCabe prefers to use pharmacologic options and almost never uses a mechanical iris expansion device because of the potential damage to the iris. If you can avoid that and keep the pupillary margin without any physical trauma, you end up with a postop pupil that looks untouched and pristine, she said. Dr. McCabe uses Omidria (phenylephrine and ketorolac, "“iÀœÃ® >˜` w˜`à ˆÌ ÛiÀޅi«vՏ intraoperatively in providing the iris with more tone and sustained dilation. Sometimes even with adequate dilation to begin with, dilation can be lost as surgery progresses, she said. Additionally, Dr. McCabe said she sometimes uses compounded phenylephrine. The compounded intracameral injection, which is phenylephrine with lidocaine, helps maintain dilation, she said. She also employs viscoelastics in her cases. Dr. Williamson said that he tries to use both pharmacologic and mechanical options. “The pupil is never going to be any bigger than what you see at the start of the case,” he said. Dr. Williamson uses Shugarcaine on every case, which gives some pharmacologic dilation and stiffens the iris a bit. “I have a low threshold to use an iris expander,” he said. Sometimes the Shugarcaine alone gives cataract access without using an iris expander, but sometimes it doesn’t. He added that some patients may require mechanical dilation, particularly those on tamsulosin or those who have iris trauma. He said to be mindful of patients with posterior synechiae as well as those with uveitis. Sometimes even narrow angle glaucoma patients can be slow on dilation. Dr. Agarwal said that while he likes pharmacologic options, they don’t always work for his cases. Pharmacologic options >Ài Li˜iwVˆ>]…i Ã>ˆ`] LiV>ÕÃi they are easy to install and don’t destroy the iris structure. There are no manipulation issues that occur with devices. However, Dr. Agarwal said that in many cases he sees, the patient also has an underlying condition, which means it’s often necessary to use some form of mechanical iris expansion. In these patients, he prefers to use iris hooks, which can be utilized in pretty much any case. Choosing among Omidria, iris stretch, or pupil dilation with a device Dr. Williamson said he doesn’t personally have experience using Omidria and prefers a device versus using mechanical stretch because you can expand the iris at once. Recently, Dr. Williamson has been using the XpandNT Iris Speculum (Diamatrix). He previously employed the >ÞÕ}ˆ˜ Àˆ˜}] LÕ̅i w˜`à the XpandNT device to be a little more atraumatic with the perfect amount of expansion. /…i Vœ˜ÌœÕÀ wÌà œ˜ ̅i ˆÀˆÃ >˜` leaves it with a little less trauma, he said. Dr. McCabe prefers Omidria because there is less likelihood of trauma to the iris, which can result in some postoperative ˆ˜y>““>̈œ˜] Åi Ã>ˆ`° There are some cases where Omidria may not work, Dr. McCabe added. If you have posterior synechiae where the pupil is bound down to the anterior capsule, it doesn’t matter what pharmacologic agent you use, it’s not going to dilate the pupil, she said. Once you stretch the pupil, which is Dr. McCabe’s “go-to technique,” it should dilate, and Omidria helps maintain that dilation. In the case of posterior synechiae, you can’t really dilate without stretching the pupil, she said, adding that she uses two Kuglen instruments, usually with the assistance of dispersive viscoelastic. IFIS and iris prolapse When dealing with IFIS, Dr. Agarwal said it’s important not to wait too long to put in an iris hook or Malyugin ring because ˆÌ V>˜ LiVœ“i “œÀi y>VVˆ` >˜` laxer. “My one tip would be by Ellen Stodola EyeWorld Senior Staff Writer / Meetings Editor AT A GLANCE • When dealing with iris prolapse, make sure you don’t place your incision too far posterior. • Using a pharmacologic option could help avoid trauma to the iris. However, sometimes these options don’t work, at which time you may want to employ a mechanical iris expansion option. • In cases of IFIS, look for any signs of trauma and for any type of synechiae preoperatively. Dealing with the unruly iris Contact information #ICTYCN | agarwal.ashvin@gmail.com /E%CDG | cmccabe13@hotmail.com 9KNNKCOUQP | blakewilliamson@weceye.com This article originally appeared in the September 2019 issue of EyeWorld . +V JCU DGGP UNKIJVN[ OQFKƂGF CPF appears here with permission from the ASCRS Ophthalmic Services Corp.