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C manipulator. When it comes time to take it out, disengage all the scrolls starting with the distal scroll. Then, give a slight clockwise rotation of the ring to make the subincisional scroll more accessible to engage with the hook on the inserter device. Other advice from the panel included tightening iris hooks only after all of them are placed, avoid making incisions too posterior, and iris hooks and capsule hooks are not neces- sarily interchangeable. If the iris billows when you inject lidocaine at the beginning of the case, Dr. Rao said it's probably a better candidate for epi-Shugarcaine or iris hooks rather than a Malyugin ring because a very floppy iris can be- come disengaged from the ring halfway through the case. Not a routine IOL positioning Manjool Shah, MD, described a case that no one wants to get at 4:45 p.m. on a Friday. The patient was referred for recurrent hyphema after an IOL exchange earlier in the week. A dislocated Crystalens (Bausch + Lomb) in the bag was removed in a procedure Monday, and a scleral-fixated IOL was placed using the Ya- mane double-needle flanged haptic technique. The patient was seen Tuesday, Wednesday, and Thursday with blood from the back to the front of the eye. When seen by Dr. Shah, the patient's IOP was in the 40s, vision was hand motion, and ultrasound biomicroscopy showed improper positioning of the IOL to the iris anatomy. The IOL was implanted too anterior (1.5 mm from the limbus), and endoscopy showed haptics going through the ciliary body, Dr. Shah said. Dr. Shah went in, noting how fibrosed the haptics were even after a few days, and cut off the flanges. Sclera fixation was redone with the haptics fixated 2.5 mm from the limbus. Mea- suring back from the scleral spur correlates with intraocular anatomy while the limbus does not and is variable, Dr. Shah said. He also noted the importance of making sure the needle for the Yamane technique is perpendicular to the sclera. This, he said, ensures that you don't end up too anterior in the eye. the capacity to do that. Dr. Raju advised tilting the device a bit as you start to deploy it, making sure you get under the capsule edge. Sumitra Khandelwal, MD, said to watch where your hands are. You need to be at a 20-degree angle. If you're too flat, you'll push the lens down, she said. If you're too steep, you could put stress on the zonules 180 degrees away. "The miLOOP doesn't come out straight; it comes out and back, so understanding the anat- omy of it is important," Dr. Khandelwal said. Dr. Raju uses a second instrument to hold down one of the cut pieces, as it can sometimes pop up. She recommended bisecting the nucle- us for your first few cases before attempting to create quadrants when you are just starting out. Some people are comfortable rotating with the miLOOP, but Dr. Raju said she uses her second instrument. Small pupil management There are several ways to enlarge the pupil, Naveen Rao, MD, said, noting dilating drops, viscoelastic, epi-Shugarcaine, phenylephrine/li- docaine, Omidria (phenylephrine and ketorolac, Omeros), and mechanical options such as pupil expansion rings and iris hooks. Dr. Rao focused his discussion on the use of rings and hooks. When creating the paracen- tesis incisions for iris hooks, Dr. Rao said to aim slightly down, rather than flat. He usually starts with four hooks, but if there is iris prolapse through the main incision, it's helpful to place an extra hook just posterior to the main incision by creating a paracentesis through the anterior sclera. Dr. Rao said he prefers the 7.0 mm Maly- ugin ring (versus the 6.5 mm) because it maxi- mizes visualization and is no more difficult to insert than the 6.5 mm size. The first step to insertion is putting in dispersive viscoelastic to protect the endothelium, followed by cohesive viscoelastic to elevate the iris off of the ante- rior capsule. The distal scroll is engaged first, followed by at least one of the side scrolls, and after the injector hook is disengaged, the subincisional scroll is engaged using the Osher About the doctors Zaina Al-Mohtaseb, MD Assistant professor Department of Ophthalmology Baylor College of Medicine Houston Sumitra Khandelwal, MD Assistant professor Department of Ophthalmology Baylor College of Medicine Houston Leela Raju, MD Clinical associate professor Department of Ophthalmology New York Langone Health New York Naveen Rao, MD Assistant professor of ophthalmology Tufts University School of Medicine Boston Manjool Shah, MD Assistant professor of ophthalmology Kellogg Eye Center University of Michigan Ann Arbor, Michigan Financial interests Al-Mohtaseb: Alcon, Bausch + Lomb, Johnson & Johnson Vision, Carl Zeiss Meditec Khandelwal: Carl Zeiss Meditec Raju: None Rao: Parexel, Shire, W.L. Gore Shah: Allergan, Glaukos, Katena Dr. Al-Mohtaseb, Dr. Khandelwal, and Dr. Rao at the YES-sponsored symposium at the 2019 ASCRS ASOA Annual Meeting Source: ASCRS JULY 2019 | EYEWORLD | 27

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