EyeWorld Asia-Pacific December 2020 Issue

SECONDARY FEATURE 30 EWAP DECEMBER 2020 I ris prolapse into phaco and/or sideport incisions or trauma from it getting caught in the phaco needle is a complication that is most commonly associated with intraoperative floppy iris syndrome (IFIS). Intraoperatively, too small or too wide of an incision, use of too much ophthalmic viscoelastic device, and/or too much pressure can contribute to cases of iris prolapse or trauma. ‘This is a skill to practice’ It was 2010 and Thomas Oetting, MD, was supervising his chief resident at the time on a cataract case. The patient was on tamsulosin. “This is an example of bad things aligning to cause a problem,” Dr. Oetting said of the case. They had used intracameral epinephrine to keep the pupil, for the most part, large enough to create the capsulorhexis and allow for lens removal without hooks or rings, he said. “However, just with the last piece of nuclear material, the patient moved a bit as the surgeon came more anterior to get a piece in the subincisional area and bam! As the piece was removed, the tip caught the iris and caused significant damage,” Dr. Oetting said. The surgeon was able to remove the remaining cortical material and place the IOL without further damage, followed by two sliding Siepser, 10-0 Prolene sutures with a CTC6L needle to close the defect. “This is a skill to practice before something like this happens, and I would suggest using artificial eyes,” Dr. Oetting said, citing Phillips Studio eyes, Bioniko, Kitaro (Frontier Vision), and SimulEYE (InsEYEt) as options. “It’s very important to be prepared to be able suture the iris,” he said. “Rarely used skills like this can so easily be practiced now with the excellent simulated eyes we have in our own ORs (as there is no cadaver or animal products), using our own instruments without any special wet lab.” The patient did well postop with a little glare but otherwise “excellent return of visual function,” Dr. Oetting said. ‘Time and again, the iris comes into the phaco tip’ Manish Mahendra, MD, described in a 2019 ASCRS Annual Meeting video how iris prolapse occurred during hydrodissection on a patient where he was unaware of prior tamsulosin use. This slight bulge of iris tissue was put back in easily, but as the case progressed, the iris constricted, and at one point, iris moved into the phaco tip. “As I tried to take my nuclear pieces, time and again the iris comes into the phaco tip,” he said. With continued floppiness impacting the surgery, Dr. Mahendra inserted a Malyugin ring, finding phaco thereafter much easier. However, despite the Malyugin ring, iris prolapsed again through the sideport and the main incision. To prevent this situation, Unruly iris during cataract surgery by Liz Hillman Editorial Co-Director AT A GLANCE • Iris prolapse or iris trauma in the phaco tip is often associated with IFIS, too small or too wide of an incision, too much OVD, and/or too much pressure. • Physicians said to be careful of the last piece of nuclear material, after which the iris, due to the change of fluidics in the eye, might come toward the phaco tip. • It is important to be prepared to suture the iris in case of trauma; practice with a simulation eye. Contact information Oetting: thomas-oetting@uiowa.edu Mahendra: drmanishmahendra@gmail.com Devgan: Devgan@gmail.com This article originally appeared in the October 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Intraoperative photo showing mild iris prolapse into the incision before all cortex was removed. Iris prolapse during an IOL exchange as the surgeon was preparing to remove a Malyugin ring. Note the mild iris atrophy in addition to prolapse. Source (all): Kevin Miller, MD