CATARACT EWAP MARCH 2022 25 through this separate incision. This time he said he was able to sweep the iris back in with a blunt I/A tip. He said sometimes tapping on the roof of the incision can coax the iris back in when there is mild prolapse. Leela Raju, MD, on the panel for the session, told Dr. Rao that switching to the other wound was a great idea. “It feels like you’re failing but you’re not; you’re making it easier for yourself,” she said. How to prevent iris prolapse Whenever an eye is at risk for iris prolapse, Dr. Snyder said to stop irrigation and let the chamber shallow before removing the phaco or I/A tip. While this might sound counterintuitive, especially in shallow chambers, he said that if there is no pressure gradient for flow to occur out of the wound, the iris will not follow if there is no flow. Other advice Dr. Snyder gave was to make sure the wound is carefully constructed with a slightly more anterior internal entry into the chamber and a longer tunnel. He also advised intravenous mannitol preop in eyes with short axial lengths and mentioned use of iris hooks to dilate and stabilize the pupil with one hook under or adjacent to the wound, which was described by Thomas Oetting, MD.1 “If the iris is tethered internally peripheral to and under the wound, it cannot prolapse out,” Dr. Snyder said. What to do when the iris emerges It’s first important to determine why the iris has prolapsed. If it occurs due to a significant OP increase from a suprachoroidal hemorrhage (SCH), Dr. Snyder said no action should be taken at the wound. In this case, he said, “the iris should be left plugging the wound and the SCH and underlying cause(s) should be identified and managed. The iris becomes secondary.” If the cause of the prolapse is not due to an occurrence in the posterior segment, Dr. Snyder said the surgeon should reduce pressure in the anterior chamber before attempting to put the iris back. “This can be done by aspirating aqueous or OVD from a paracentesis, giving intravenous mannitol, or rarely, converting to general anesthesia, if patient cooperation is the origin,” he said. If/when the anterior chamber pressure has returned to at least somewhat below normal, Dr. Snyder said tapping on the roof of the corneal tunnel will usually drop the iris back in without any direct contact. However, in stubborn cases, he said the iris can be pulled into the anterior chamber with microforceps through a paracentesis on the other side. Gently grasp the iris internally and pull it into the AC, he said. Dr. Snyder said pushing the iris with an instrument through the same wound as the prolapse is less effective and can cause more stromal or pigment loss. Finally, he said another strategy when there is minimal prolapse after the chamber is depressurized is to use a gentle squirt of balanced salt solution external to the wound ostium. This can create an internally directed flow gradient and “blow” the iris in, he explained. EWAP Reference 1. Oetting TA, Omphroy LC. Modified technique using flexible iris retractors in clear corneal cataract surgery. J Cataract Refract Surg. 2002;28:596–598. Editors’ note: Dr. Rao is Assistant Professor of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts. Dr. Snyder is Professor of Ophthalmology, University of Cincinnati, Cincinnati, Ohio. Neither declared any relevant financial interests. Keratoconus Progression at a Glance! The newly integrated post-CXL function and database allow for evaluation of the cornea after crosslinking, based on the full complement of parameters including posterior corneal surface and corneal thickness at its thinnest spot. Monitor your keratoconus treatment with ease and improve your surgery outcomes! Retrospective use Free update User-friendly OCULUS Asia Ltd. www.oculus.de • info@oculus.hk KLB Instruments Co. Pvt. Ltd KLB The Belin ABCD Progression Display now includes post-CXL data
RkJQdWJsaXNoZXIy Njk2NTg0