Eyeworld

22 | EYEWORLD | JULY 2021 ASCRS/EYEWORLD JOURNAL CLUB ASCRS NEWS by Saira Khanna, MD, Shivam Amin, MD, Lindsay Chun, MD, Farida Hakim, MD, Jacob Kanter, MD, Zhuangjun Si, MD, Peter Veldman, MD inspect the location and extent of an iris defect to gauge whether it will be visually significant and determine whether to repair immediately or in a subsequent surgery. The advantages of immediate repair include limiting potential vi- sual symptoms, improved cosmesis, and avoid- ance of future scarring. Delaying repair can allow the surgeon to gauge whether a defect is visually significant enough to warrant repair. Alternatives such as prosthetic contact lenses, corneal tattooing, or topical pilocarpine can be explored. Topical NSAIDs and corticosteroids may be used in the interim to prevent excess inflammation from injured iris tissue. If proceeding with surgical repair, the authors stated the importance of selecting the appropriate modality of sedation and anesthetic and paying attention to which area of the iris is affected. The authors discussed that focal iris sphincter damage repair involves passing sutures through underactive iris and approx- imating it such that the radiality of the iris is achieved. In cases of diffuse sphincter damage, they recommended an iris cerclage technique wherein multiple paracentesis openings are used to access the iris and pass basting or whip stitches evenly spaced along the pupil margin and tied with an intraocular knot to produce a smooth, round pupil. Mid-peripheral iris defects may be re- paired by passing sutures through undamaged iris tissue on either side of the defect; larger mid-peripheral defects may require multiple sutures placed along the length of the defect. The authors offered two approaches to irido- dialysis damage repair: placement of mattress sutures through the peripheral edge of the iris defect and scleral wall or the sewing machine technique. Iris cautery is discussed as a method of reshaping the pupil with 25-gauge intraocu- lar diathermy at the pupillary margin to cause contraction of iris collagen with care to avoid over-cauterizing the iris sphincter. In cases where there is extensive iris damage or friable iris tissue that make primary surgical repair un- feasible, the authors suggested iris prosthetics. The authors discussed intraocular knots that can be used to suture iris tissue. They Review of "Management of common iatrogenic iris defects induced by cataract surgery" I atrogenic iris defects are a common compli- cation of cataract surgery that can nega- tively impact the visual function of patients. The complication rate has been reported to be 0.55–1.1%. 1,2 Patients can experience debilitating glare, halos, or have significant cosmetic concerns that may require surgical in- tervention. 3 Iris defects can be classified accord- ing to anatomic layer, size, and location and will impact the decision and type of repair. Because of the frequency, understanding how to mini- mize and manage iris defects is imperative for cataract surgeons. The authors comprehensively described not only how to approach patients to avoid iatrogenic iris trauma but also various techniques to address iris defects preoperatively, intraoperatively, and postoperatively. Summary The iris can be damaged during phacoemulsifi- cation in a myriad of ways: prolapsing through the wound, being aspirated through the hand- piece, mechanical chafing with a chopper or lens fragment, as well as generalized damage from ultrasound energy, with a small pupil being the most common risk factor. The authors discussed the risk factors for inadequate dilation including senile miosis, posterior synechiae, pseudoexfoliation, and systemic medications, most commonly alpha-1a adrenergic antago- nists, which also cause intraoperative floppy iris syndrome (IFIS). Thorough preoperative review for these risk factors, discontinuation of miotic agents, ophthalmic viscosurgical devices, and additional mydriatics or preoperative NSAID use to maintain intraoperative dilation are potential pharmacologic recommended strategies. Surgical strategies to protect the iris include attention to fluidics and wound construction to prevent anterior chamber turbulence and iris prolapse. The authors also discussed techniques for the enlargement of small pupils including stretch pupilloplasty with Kuglen hooks and Vannas scissors and the insertion of devices such as iris hooks and pupil expansion rings. If an iris defect does occur, the authors rec- ommended that during surgery the surgeon first Peter Veldman, MD Residency Program Director University of Chicago Chicago, Illinois

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