EyeWorld Asia-Pacific December 2019 Issue

EWAP DECEMBER 2019 11 FEATURE to immediately start using an expansion device,” Dr. Agarwal said. “Once you’ve done that, use high-density cohesive viscoelastic.” He added that he always has a second instrument in his left hand (with the phaco probe in his right hand) so that it holds in the iris that is coming toward the globe and keeps it at bay and away from the probe. He also stressed the importance of keeping the tool in the center of ̅i «Õ«ˆ ̜ >ۜˆ` V…>w˜}° Dr. Agarwal offered several other tips on iris prolapse. “Other than prevention, the wÀÃÌ ÀՏi ˆÃ ˜iÛiÀ “>Ži >˜ incision too posterior,” he said. The minute you make a posterior incision, you will have iris coming because there’s no barrier to the iris structure. His second point was to avoid over injecting the anterior chamber with viscoelastic. That will push the iris up and out, making it balloon and be pushed out of the eye through the incision. If this happens, he suggested reducing the pressure inside the eye and taking out as much viscoelastic as possible. Dr. McCabe said that ideally, she would prefer to have Omidria on every case. There >Ài > È}˜ˆwV>˜Ì ˜Õ“LiÀ œv V>Ãià where surgeons don’t know preoperatively that they will encounter IFIS intraoperatively. “In those cases, if I have Omidria on board, I know I already have some control over what’s happening with the iris,” she said. In cases requiring something different intraoperatively, additional dispersive viscoelastic can be helpful. For iris prolapse, when you are aware preoperatively that you have IFIS, Dr. McCabe said making a perfect geometry of the main incision is important. You want a self-sealing incision, you don’t want to make a short incision, and you don’t want one XpandNT device placed in an IFIS patient with miotic pupil at time of phaco. Source: Blake Williamson, MD Mohan Rajan, FRCS, Phd Chairman and Medical Director, Rajan Eye Care Hospital Pvt Ltd #5 Vidyodaya 2nd Street, T. Nagar, Chennai-600017, India drmohanrajan@gmail.com ASIA-PACIFIC PERSPECTIVES 56'25 61 +(+5 57%%'55| £® /…i “œÃÌ Vœ““œ˜ V>ÕÃi œv ˆ˜ÌÀ>œ«iÀ>̈Ûi yœ««Þ ˆÀˆÃ Ãޘ`Àœ“i (IFIS) is that patient is on Urimax (for BPH). Stopping Tamsulosin preop doesn’t help in pupillary dilatation intraop. Pupil less than 6 mm dilatation—severe IFIS. 2) I USE INTRACAMERAL PHENOCAINE (propracaine + phenylephrine preservative-free) routinely. This has a dilating effect on a pupil that was not previously dilating for the regular topical dilating drops preoperatively. 3) I USE TRYPAN BLUE ASSISTED CAPSULORRHEXIS , preferred in all cases of IFIS. This enables us to visualize this margin even if the pupil comes down. For small pupil around 4.5 to 5 mm, I use pupil maximized center in femto cataract for capsulorhexis of 4.6 to 4.9 mm which helps in i>ÃÞ «…>Vœi“ՏÈwV>̈œ˜ œv ̅i vÀ>}“i˜Ìi` ˜ÕViÕð 4) I MAKE A WELL-CONSTRUCTED TRIPLANAR CORNEAL INCISION which avoids intraop iris prolapse. This is better facilitated by the femto cataract corneal incision. I would prefer an anterior and long corneal incision. More posterior wound can prolapse the iris more easily through it. A well-constructed, self- sealing wound prevents the iris from prolapsing through the ports. 5) + 75' *KIJ FGPUKV[|18&5 (healon5, viscoat, discovisc) to push the prolapsed iris into the anterior chamber. It also dilates the pupil and pushes the iris back from the wound. I would not use too much OVD as it can increase the intraocular pressure and cause iris prolapse. 6) I WOULDN’T ALLOW THE FLOPPY IRIS TO DANCE FURTHER , vœÀ ܅ˆV…ܜՏ` ÕÃi œÜ yՈ`ˆVà `iVÀi>Ãi ̅i LœÌ̏i…iˆ}…Ì] œÜ Û>VVÕՓ] œÜ >ëˆÀ>̈œ˜ yœÜ À>Ìi®ÉœÜ «…>Vœ° ˆ}…>ëˆÀ>̈œ˜ yœÜ À>Ìi V>˜ V>ÕÃi ̅i ˆÀˆÃ ̜ LiVœ“i yœ««ˆiÀ° ˆ}…Û>VÕՓ V>˜ V>ÕÃi the iris dislodging into the phaco tip causing further constriction of pupil and trauma to the iris. 7) If the PUPIL DILATATION IS LESS THAN 6 MM I would straight away use mechanical pupil expanders such as iris hooks, Malyugin rings, B Hex ring. Usually 3-4 iris hooks are used for a better visualizing during surgery. I would consider the hardness of cataract and preop pupil size as well to decide when to use mechanical pupil expanders. In cases above nuclear sclerosis grade 3, I would prefer iris hooks to other pharmacological maneuvers intraop. 'FKVQTUo PQVG &T 4CLCP FGENCTGF PQ TGNGXCPV ƂPCPEKCN KPVGTGUVU continued on page 16