EyeWorld India September 2020 Issue

24 EWAP SEPTEMBER 2020 CATARACT by Maxine Lipner Senior Contributing Writer Contact information Koch: dkoch@bcm.edu Oetting: thomas-oetting@uiowa.edu This article originally appeared in the May 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. H ooks and expansion rings can be an ophthalmologist’s partner when performing phacoemulsification. Douglas Koch, MD, relies on pupillary expansion devices when there’s a risk of inadequate visualization or the potential for iris trauma (via accidental engagement with the phaco tip or through some other manipulation). “When I’m doing phacoemulsification, if the iris is not particularly floppy, I’m comfortable working through pupils as small as 4 mm,” Dr. Koch said. “When I’m doing an IOL exchange, I may need to visualize the haptics and their location in the capsular fornix. That requires a pupil size that’s 8 mm or larger, so I may need to use iris hooks in the area of the haptics in order to get visualization for that.” In the case of a subluxated lens and capsule, Dr. Koch usually performs scleral fixation of the IOL and capsule. With this procedure, it’s important to see where the haptics are, which may mean enlarging the pupil to 7 mm. Thomas Oetting, MD, relies on pupil expansion devices when a patient is on an alpha blocker or has a past history of uveitis. If the pupil is small because drops weren’t given in time, he said he may proceed with the aid of some epinephrine and insert a device later, if needed. Considering pupil devices When deciding between pupil expansion devices or iris hooks, Dr. Oetting considers other hardware he might need inside the eye, such as a capsular tension segment or an especially big lens. “I think iris hooks are good if you want to be 100% sure there’s no prolapse,” Dr. Oetting said, adding that for most patients with a reasonable chamber depth, he finds it quicker to use a Malyugin ring. Dr. Koch uses a pupil expansion ring if the iris is not fibrotic. “Whenever I see the pupil is too small and I need to enlarge it to 6 mm and I don’t see a lot of fibrosis, I use the Malyugin ring,” Dr. Koch said. However, he avoids these rings in cases where there is a lot of iris fibrosis because he’s concerned it could lead to asymmetrical tears. He’ll instead rely on iris hooks so he can titrate the amount that he opens. Dr. Koch said he’ll also use iris hooks when he wants to better visualize one section of the eye. If the iris is floppy due to IFIS, however, he injects 1:5,000 epinephrine at the beginning of the case. This gives him enough stability and adequate pupil size to complete the case, sometimes in conjunction with reinjecting dispersive OVD. Dr. Oetting uses intracameral Placing hooks, rings, and things A capsular tension ring is inserted with 3 clock hours of traumatic zonular loss. Because the remaining zonules were intact, the ring provided sufficient support for the capsule and IOL. In this case of nasal traumatic zonular loss, three Mackool hooks were inserted to support the lens during phacoemulsification. After all lens material was removed, a CTR was inserted, and an Ahmed segment was sutured to the sclera to provide good long- term capsular support. Source (all): Douglas Koch, MD