SEP 2019

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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I CHALLENGING CATARACT CASES N FOCUS 54 | EYEWORLD | SEPTEMBER 2019 Contact information Agarwal: agarwal.ashvin@gmail.com McCabe: cmccabe13@hotmail.com Williamson: blakewilliamson@weceye.com pushes the iris posterior to the incision's inner lip. If the main incision is poorly constructed, it may make sense to create a better incision adja- cent to the original incision, Dr. McCabe said. Small pupils present another challenge. Steps to help facilitate a successful case include good hydration and good lens mobility prior to removing any segments of the nucleus during phaco. Take extra time with hydrodissection to make sure the lens is freely mobile. Dr. McCabe added that with a small pupil, be sure that you have all the cortical pieces and no nuclear frag- ments are hiding, especially as you're getting to the completion of I/A and cortex removal. With the anterior chamber and bag filled with viscoelastic or with the I/A handpiece in the AC, she uses a Kuglen or second instrument through the paracentesis and carefully moves the edge of the pupil and dilates it 360 degrees around by moving the pupil and iris margin peripherally, peeking underneath to make sure there's no retained cortex or missed nuclear material. She also recommended looking again after placing the IOL. In cases of IFIS when the iris comes out, Dr. Williamson said he likes to depress from the back of the wound to deflate the AC and lower the pressure. "I find that by letting all the fluid come out of the AC by depressing the posterior lip of the main incision, you can easily deposit the iris back in," he said. After that, he places a cohesive viscoelastic onto the iris for good spacing between the incision and iris. Preoperatively, Dr. Williamson said to look for any signs of trauma and synechiae. He also said to be aware if the patient has had laser sur- gery on the iris and to review any medications that patient is on. Try to be as atraumatic as possible with iris expander devices in cases of iris prolapse, he warned. Even with moderate manipulation of the iris, you can get iris atrophy. Dr. Williamson also mentioned IFIS when using the femtosecond laser, adding that he uses the femtosecond laser for about 60–70% of his patients. "I've taken great care in these patients to put several dilating drops in after the femto- second laser is completed," he said. IFIS and iris prolapse When dealing with IFIS, Dr. Agarwal said it's important not to wait too long to put in an iris hook or Malyugin ring because it can become more flaccid and laxer. "My one tip would be to immediately start using an expansion device," Dr. Agarwal said. "Once you've done that, use high-density cohesive viscoelastic." He always has a second instrument in his left hand (with the phaco probe in his right hand) so that it holds in the iris that is coming toward the globe and keeps it at bay and away from the probe. He also stressed the impor- tance of keeping the tool in the center of the pupil to avoid chafing. Dr. Agarwal offered several other tips on iris prolapse. "Other than prevention, the first rule is never make an incision too posterior," he said. The minute you make a posterior incision, you will have iris coming because there's no barrier to the iris structure. His second tip was to avoid over injecting the anterior chamber with viscoelastic. That will push the iris up and out, making it balloon and be pushed out of the eye through the incision. If this happens, he suggested reducing the pressure inside the eye and taking out as much viscoelastic as possible. Dr. McCabe said that ideally, she would prefer to have Omidria on every case. There are a significant number of cases where surgeons don't know preoperatively that they will en- counter IFIS intraoperatively. "In those cases, if I have Omidria on board, I know I already have some control over what's happening with the iris," she said. For iris prolapse, when you are aware preop that you have IFIS, Dr. McCabe said making a perfect geometry of the main incision is important. You want a self-sealing incision, you don't want to make a short incision, and you don't want one that's too wide, she said. The incision needs to be properly placed and not too far posterior because this will also facilitate iris egress from the incision. If you do get iris prolapse, decompress the AC by releasing fluid or viscoelastic from the paracentesis and gently reposit the iris, she said. To do that, she uses a dispersive viscoelastic because, as you reposit the iris, you can use the viscoelastic to create a gentle blockade that continued from page 52 About the doctors Ashvin Agarwal, MD Dr. Agarwal's Eye Hospital Chennai, India Cathleen McCabe, MD The Eye Associates Bradenton, Florida Blake Williamson, MD Williamson Eye Center Baton Rouge, Louisiana Relevant financial interests Agarwal: None McCabe: Omeros Williamson: None

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