19 EyeWorld Asia-Pacific | June 2025 CATARACT Prolapse Management Dr. Tipperman said prolapse is most likely to occur early in the case when you have made the incision and you put in viscoelastic. In some cases, it occurs when you make the paracentesis, which is a sign “you’re going to be battling it all day,” he said, though this is less common. “It’s more common that the iris will come out through the main incision.” At this point, Dr. Tipperman said to pause and assess the situation. Say to yourself, “Why is this occurring?” “If it’s pharmacologic, a lot of people, myself included, think that putting some sort of agent in the anterior chamber like epinephrine will stiffen the iris and prevent some of the billowing and the prolapse. Some people will use iris hooks also,” he said. “If it’s coming from positive pressure, are you putting too much pressure on the eye with the way the speculum is? Did you put in too much viscoelastic; do you need to burp some out? Or is it your incision—did you happen to enter a little too posteriorly, or is your incision a little too shallow and the iris is coming out?” Dr. Tipperman said when the iris keeps coming out of the main incision due to wound construction, one option is to place a Sheet’s glide through the incision over the iris to push it back and protect it from the phaco. Another option is to sweep the iris back in, suture the incision, and move a few clock hours away. The latter, he said, takes a little bit more time, but makes the remainder of the case smoother. Dr. Meghpara said when prolapse occurs, “don’t panic.” “You don’t want to turn something that is fairly easy to manage, do the wrong things, and turn it into a much bigger situation,” he said. “The first thing is avoid trying to push it back in or trying to fill up the anterior chamber with more viscoelastic to push it back in. You want to decrease the pressure in the anterior chamber. The way you do that is you shallow it through a paracentesis; resist the urge to touch the iris immediately.” Once the pressure is lower, he said to use a blunt instrument through a paracentesis to sweep the iris back into the eye. “We’re not pushing it in but sweeping it from inside and sweeping it out of the incision back into the anterior chamber,” he explained. After one prolapse, Dr. Meghpara said the iris tends to want to do it again, so he’ll adjust his phaco settings to low flow, decreasing the bottle height and lowering the vacuum and aspiration rates so there is less fluid going behind the iris. “Sometimes once you get it in the eye, you can put a very small amount of high viscosity viscoelastic on top of the iris by the incision to push it backward. You don’t want to overfill the anterior chamber with viscoelastic completely because then you’ll prolapse out again because you’ve created too much pressure in the anterior chamber, but a very selective amount right in the area of prolapse will help,” he said. If it keeps prolapsing out despite these efforts, Dr. Meghpara will employ iris hooks (usually four in a diamond shape to keep the iris taut) or a Malyugin ring. “What you can also try to do is put in iris hooks or the Malyugin ring and constrict the pupil, with an intracameral miotic. … You need the pupil dilated to finish up the surgery, but if you have the pupil contracting against a Malyugin ring, it’s going to be more taut. That may help reduce the floppiness.” Another option Dr. Meghpara offered, if the iris keeps prolapsing out, to avoid damaging the tissue, is to leave it out of the wound, finish the cataract portion of the case, and sweep the iris back into the eye at the end of the case. “It’s out of the eye but at least you’re manipulating it less. That’s the last-ditch effort to finish the case because every time you touch it, you’re creating defects in the iris and you could have a bigger issue after the fact trying to repair that,” he said. Postop, if there are no significant iris defects caused by the prolapse and subsequent manipulation to get it back into the eye, the patient should not experience any issues. If there are significant iris defects, both Dr. Tipperman and Dr. Meghpara said they tell the patient that the case was difficult and that if they experience visual disturbances due to the iris defect, they can fix it. Dr. Meghpara added that with the extra manipulation in these cases, patients who experienced iris prolapse can be more prone to CME, so he advised an NSAID postop. About the Physicians Beeran Meghpara, MD | Co-Director of Refractive Surgery, Wills Eye Hospital, Philadelphia, Pennsylvania | bmeghpara@willseye.org Richard Tipperman, MD | Attending Surgeon, Wills Eye Hospital, Philadelphia, Pennsylvania | rtipperman@mindspring.com This article originally appeared in the March 2025 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Relevant Disclosures Meghpara: None Tipperman: None
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