EyeWorld India June 2021 Issue

CATARACT EWAP JUNE 2021 23 by Ellen Stodola Editorial Co-Director Contact information Foster: gjlfos@gmail.com This article originally appeared in the March 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services A paper published online ahead of print in the Journal of Cataract & Refractive Surgery 1 covered the topic of managing iris defects that can be caused by cataract surgery. Gary Foster, MD, one of the paper’s authors, gave EyeWorld insights on the paper, “Management of common iatrogenic iris defects induced by cataract surgery.” Iris defects are a common complication that can occur during cataract surgery. These are issues that surgeons are likely already aware of, and they have probably seen all of them, Dr. Foster said. The paper describes classification, prevention, surgical strategy, deciding when to repair, and repair techniques. No matter how skilled a surgeon is at preventing iris injury, he or she can still be involved in causing these, Dr. Foster said. “It behooves surgeons to be as skilled as possible at preventing them and having a plan for how to repair them when they occur.” Dr. Foster said one of the most common iris defects during cataract surgery is IFIS. When a patient has IFIS, the iris may jump up to the wound during surgery. If the patient has a mid- stromal defect, which is one of Paper highlights iris defects caused by cataract surgery the categories discussed in the paper, Dr. Foster said this may not always need to be fixed, but if it’s a large defect and you think the patient will have symptoms, it’s good to fix that. “You have to decide if the defect is likely to cause challenges and if the risk to fix is greater than the risk of the patient having symptoms,” he said. Dr. Foster added that a high percentage of patients have been on one of the drugs that cause IFIS. Prevention is another way to help reduce the likelihood of inducing iris defects. Using non- steroidal drops ahead of time and/or non-steroidal medication administered intracamerally during cataract surgery can help prevent this, Dr. Foster said. He added that it’s important to slowly do hydrodissection so you don’t pressurize the chamber to a level that the iris is forced out. Additionally, Dr. Foster suggested using OVD in a manner to tamponade the iris and decrease the chances that it would exit the eye when instruments are going in or out of the eye. “In extreme cases, it’s helpful to inject OVD at the wound site before removing an instrument from the eye,” he added. Defects can occur at any time during cataract surgery, Dr. Foster said, though hydrodissection is a high- risk event, as is when you’re aspirating fluid toward the tip. If the iris is caught in that stream, it will be drawn into the phaco tip and will be damaged. Withdrawing the instrument from the eye is also a time when the iris may lurch toward the wound, Dr. Foster said. Lastly, he said hydrating the wound at the end of the case can create a high pressure within the eye that draws the iris to the wound. Dr. Foster reiterated that it’s important to judge if the patient is likely to have symptoms from the defect based on its location and size and whether they are likely to find it objectionable cosmetically. There are a variety of options outlined in depth in the paper if a repair is necessary. Dr. Foster noted that the online version of the article offers practical advice in the form of figures and videos. “Everyone knows they cause [the defects], but what’s exciting about the article is the description and video work on how to prepare,” he said. EWAP Reference 1. Foster G, et al. Management of common iatrogenic iris defects induced by cataract surgery. J Cataract Refract Surg. 2020. Online ahead of print. Editors’ note: Dr. Foster practices at the Eye Center of Northern Colorado, Fort Collins, Colorado, and declared no relevant financial interests.