MAY 2013

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

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18 EW NEWS & OPINION May 2013 Tools & techniques Inserting the Malyugin Ring by Boris Malyugin, MD I have found the Malyugin Ring to be one of the most valuable adjunctive devices I utilize in complicated cataract surgeries. Whether it is a pseudoexfoliation eye or a floppy iris case, the presence of a Malyugin Ring will in most instances turn a potentially disastrous procedure into a mostly routine one. The small added cost of the ring more than covers the cost of a peptic ulcer or antidepressants. Most inventive devices and techniques will strike the average ophthalmologist with the classic, "Duh, why didn't I think of that?" The Malyugin Ring is an ingenious tool that begs me to ask the question, "How in the world did he ever come up with that thing?" There is no "duh" moment with this device, more like a "Which planet did the aliens who gave Dr. Malyugin this device come from?" In this month's column, we have the pleasure of having Dr. Malyugin present his tips and pearls for utilizing the Malyugin Ring. The maneuvers for avoiding removal complications with incisions smaller than 2.2 mm are especially useful, and although I have been using this gadget for years, I learned a new trick after reading his article. For those of you who have not used the ring yet, I encourage you to review the column and give it a try. D ifferent techniques of modern cataract surgery require a wide and unobstructed view of the lens. When a pharmacological approach is insufficient, the surgeon usually favors the use of the mechanical pupil expansion device. Not surprisingly, my personal preference is the Malyugin Ring— the device having a one-piece design and square shape with four equidistantly located circular loops, used to capture the iris margin. In spite of the rectangular shape, the Malyugin Ring provides the round pupil as a result of an eight-point pupillary margin fixation (Figure 1). The Malyugin Ring System produced by MST (MicroSurgical Technology, Redmond, Wash.) consists of a pre-sterilized single-use holder containing the ring and inserter. The ring comes in two sizes: 6.25 mm and 7.0 mm. The advantage of the smaller ring is that it is easier to insert and to remove, while the bigger one can be used if the pupil starts off bigger, like in IFIS cases. Surgical technique The implantation and removal of the Malyugin Ring is performed with the same insertion device and assisted with the second instrument introduced through the side port. The ring is usually introduced at the very beginning of phacoemulsification through the main incision. But in case of progressive intraoperative pupil constriction, the ring can be inserted at any stage of the procedure. The techniques of the Malyugin Ring insertion/removal vary depending on the size of the incision. Small incision cataract surgery (≥2.2 mm) With 2.2 mm and larger incisions, the inserter passes easily through the corneal tunnel into the anterior chamber. It is advisable to avoid overfilling the anterior chamber with OVD in order to avoid pressing the iris against the anterior lens capsule. I like to position the tip of the injector close to the pupillary margin and then push the thumb button. The ring is moved forward, and its distal scroll is engaged with the iris (Figure 2). The injection continues, while the inserter is slowly moved backward toward the main incision. When the lateral scrolls emerge from the tube of the inserter, one or both of them simultaneously catch the iris margins. As soon as the proximal scroll is expelled from the inserter cannula, the inserter is retracted completely from the eye. Sometimes the surgeon has to push the ring slightly to the side to allow the inserter to exit out of the eye. In some cases it is useful to disengage the proximal scroll from the injector with the help of the instrument, incontinued on page 20 Richard Hoffman, MD, Tools & techniques editor Figure 1. Malyugin Ring in place, providing the eight-point pupil fixation Figure 2. Malyugin Ring insertion. The tip of the inserter is positioned close to the iris, and the distal scroll of the ring is engaged with the pupillary margin. Figure 4. Wound-assisted Malyugin Ring insertion through the 1.8 mm incision Figure 3. Malyugin Ring removal. The ring manipulator is pressing on both lateral scrolls in order to guide them inside the inserter tube. Figure 5. Malyugin Ring removal through the 1.8 mm clear corneal incision Source (all): Boris Malyugin, MD

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