Eyeworld

JULY 2021 | EYEWORLD | 23 continued on page 24 References 1. Syed ZA, et al. Cataract surgery outcomes at a UK independent sector treatment centre. Br J Oph- thalmol. 2015;99:1460–1465. 2. Norregaard JC. Results from the International Cataract Sur- gery Outcomes Study. Acta Oph- thalmol Scand. 2007;85:5–32. 3. Dunn SP, Stec L. Iris Recon- struction. In: Macsai, MS (Ed.). Ophthalmic Microsurgical Sutur- ing Techniques. Springer Berlin Heidelberg. 2007:71–83. 4. Wilson CW, et al. Pupil expan- sion device use and operative outcomes with topical dilation vs intracameral epinephrine in resident-performed cataract surgery. J Cataract Refract Surg. 2020;46:562–566. 5. Silverstein SM, et al. Effect of phenylephrine 1.0%–ketorolac 0.3% injection on tamsulosin- associated intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2018;44:1103–1108. 6. de Faria A, et al. Same-eye comparison of pupillary dilation with an intraoperative standard- ized intracameral combination of mydriatics (Mydrane®) versus a preoperative ophthalmic (Mydriasert®) in standard cataract surgery in non-dia- betic patients. J Fr Ophtalmol. 2019;42:e339–e348. 7. Nderitu P, Ursell P. Iris hooks versus a pupil expansion ring: Operating times, complications, and visual acuity outcomes in small pupil cases. J Cataract Refract Surg. 2019;45:167–173. 8. Alio JL, et al. Keratopigmen- tation (corneal tattooing) for the management of visual disabilities of the eye related to iris defects. Br J Ophthalmol. 2011;95:1397–1401. for enhancing dilation. The literature largely supports intracameral use of medications over topical dilating drops alone, especially for patients who are at risk for IFIS. Wilson et al. looked at the need for pupil expansion devices (PED) with topical versus intracameral dilation and found that intracameral dilation significant- ly decreased the need for PED use, especially in patients on tamsulosin. 4 In addition to cost-sav- ing benefits, there was presumably less iris ma- nipulation/injury in cases not requiring PEDs. A small randomized controlled trial showed that there was less iris prolapse and billowing in patients on tamsulosin who received phenyl- ephrine and ketorolac in the irrigation solution compared to those who received balanced salt solution alone. 5 The authors do not mention Mydriasert (Thea Pharmaceuticals), a tropi- camide/phenylephrine pill-like implant that is inserted in the inferior fornix. One study com- pared a cocktail of intracameral tropicamide, phenylephrine, and lidocaine vs. Mydriasert and found that the implant provided almost an additional millimeter of dilation. 6 In discussion of surgical strategies, the au- thors' attention to fluidics and wound construc- tion is particularly useful for surgeons early in their training. There may be a temptation to use continuous irrigation for ease of maintaining the anterior chamber stability. However, irriga- tion while exiting the wound may promote iris prolapse. One discussant suggested that if iris prolapse due to an unstable wound occurs more than once during a case, the surgeon may con- sider closing the wound with sutures and cre- ating a better incision elsewhere to reduce risk of iris injury during the rest of the case. In the discussion of methods for pupil enlargement, the authors described the advantages and disad- vantages of each technique. Iris hooks increase surgical time compared to pupil expansion rings but are more versatile intraoperatively. Pupil expansion rings have also been associated with higher rates of postoperative corneal edema and uveitis. 7 discussed the forces that comprise a knot's hold- ing strength: internal friction (suture on suture from multiple throws) and external friction (from the surrounding iris); they stated that a 2-1-1 configuration strikes the right balance between security and ease with which it can be pulled into the eye. The authors then detailed the Siepser knot and several of its variations. These include the Osher-Cionni-Snyder, Con- don, Ahmed, and Narang-Agarwal variants, which differ in their means of tying, but all involve externalizing the throws and pulling to tighten over the iris. The authors discussed the Ogawa knot and the Ahmed variant, which are similar to the Siepser in that the knot is formed outside the eye but differ in their use of an IOL manipulator to slide the knot onto the iris. They also mentioned the Ahmed 2-intraocular forceps knot, which is the only knot to be performed entirely within the anterior chamber. Discussion The authors provided an excellent overview of risk factors for iris injury due to a small pupil, along with various pharmacological options The ASCRS Journal Club is a virtual, compli- mentary CME offering exclusive to ASCRS members that brings the experience of a lively discussion of two current articles from the Journal of Cataract & Refractive Surgery to the viewer. Co-moderated by Nick Mamalis, MD, and Leela Raju, MD, the May session featured a presentation by Cherie Fathy, MD, and discussion by Terry Kim, MD, co-authors of "When ophthalmology goes virtual amid a pandemic: content analysis of the 2020 #ASCRSVirtualMeeting." The second manu- script, "Management of common iatrogenic iris defects induced by cataract surgery," was presented by Saira Khanna, MD, oph- thalmology resident, University of Chicago. To view the May Journal Club session, visit ascrs.org/clinical-education/journal-club/ schedule/may-2021. From left: Saira Khanna, MD, Shivam Amin, MD, Lindsay Chun, MD, Farida Hakim, MD, Jacob Kanter MD, Zhuangjun Si, MD, ophthalmology residents, University of Chicago

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