Eyeworld

36 | EYEWORLD | DECEMBER 2021 COMPLICATED CASES ATARACT C by Liz Hillman Editorial Co-Director About the physicians Naveen Rao, MD Assistant Professor of Ophthalmology Tufts University School of Medicine Boston, Massachusetts Michael Snyder, MD Professor of Ophthalmology University of Cincinnati Cincinnati, Ohio eyes. He followed up this difficult case with the second eye where he applied lessons learned from his experience with the first. The case presented during the ASCRS Young Eye Surgeons Clinical Committee Com- plications by Proxy symposium at the 2021 ASCRS Annual Meeting involved a 75-year-old woman who was hyperopic, had shallow an- terior chambers, prior laser peripheral iridoto- my, and a BCVA of 20/80 in her right eye and 20/100 in her left. Her first eye's axial length was 20.24 mm with an anterior chamber depth of 2.02 mm. Dr. Rao said he used topical and intracameral lido- caine, but as soon as he made the paracentesis and injected "the tiniest bit of lidocaine, the eye turned rock hard." There was iris prolapse through the paracentesis. Dr. Rao tried to burp out some of the fluid, but the iris was plugging the incision. He said he was worried about the high pressure causing a CRAO, so he made a rapid temporal corneal incision to decompress the eye as soon as pos- sible. It was a uniplanar incision, and immedi- ately, iris prolapse occurred again due to the shallow anterior chamber and the architecture of the incision. "Every time I would sweep the iris back in using a cyclodialysis spatula, it would come right back out," he said. He phacoed through the incision and said, in retrospect, he should have put an iris hook posterior to hold the iris subincisionally. He was able to phaco successfully but found IOL insertion difficult because the iris kept trying to prolapse through the incision. He abandoned that incision, created a new incision superiorly, and successfully inserted the lens. Even when he was trying to suture the temporal incision at the end of the case, the iris continued to prolapse as he tried to pass the needle. A Sheets glide to hold the iris back was unsuccessful. In the end, there was significant iris atrophy temporally, which was later re- paired with pupilloplasty. Dr. Rao applied the lessons he learned in this case to the second eye, which had an axial length of 20.08 mm and an anterior chamber depth of 2.01 mm. This time he used general anesthesia and intravenous mannitol preop. Preventing and managing iris prolapse Dr. Rao experienced iris prolapse at the start of a cataract case involving a nanophthalmic eye. Despite several management efforts, the iris continued to come out of the wound. Dr. Rao applied lessons learned in this first eye when he operated on the second. Source: Naveen Rao, MD I ris prolapse can occur at any time during cataract surgery when the pressure inside the eye is higher than the pressure outside and when there is an open wound, said Michael Snyder, MD. There are certain con- ditions, he explained, that increase the potential for iris prolapse: light blue iris, poor dilation, short axial length, shallow anterior chamber, too short of a wound, too posterior of an internal incision, and/or excessive pressurization of the globe with too much OVD. How commonly (or uncommonly) iris pro- lapse occurs is surgeon dependent, Dr. Snyder said. "Mild prolapse may occur in double-digit percentages for some, while others may en- counter this problem in only a fraction of a percentage. It is all about wound construction and attentiveness to micro-pressure gradients. As with so many things, prevention is the best management," he said. A case in point Naveen Rao, MD, presented an example of a difficult iris prolapse case in nanophthalmic

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