Eyeworld

DECEMBER 2021 | EYEWORLD | 37 C Contact Rao: naveen.k.rao@lahey.org Snyder: Msnyder@cvphealth.com Reference 1. Oetting TA, Omphroy LC. Mod- ified technique using flexible iris retractors in clear corneal cata- ract surgery. J Cataract Refract Surg. 2002;28:596–598. Relevant disclosures Rao: None Snyder: None What to do when the iris emerges It's first important to determine why the iris has prolapsed. If it occurs due to a significant IOP increase from a suprachoroidal hemorrhage (SCH), Dr. Snyder said no action should be taken at the wound. In this case, he said, "the iris should be left plugging the wound and the SCH and underlying cause(s) should be identified and managed. The iris becomes secondary." If the cause of the prolapse is not due to an occurrence in the posterior segment, Dr. Snyder said the surgeon should reduce pressure in the anterior chamber before attempting to put the iris back. "This can be done by aspirating aqueous or OVD from a paracentesis, giving intrave- nous mannitol, or rarely, converting to general anesthesia, if patient cooperation is the origin," he said. If/when the anterior chamber pressure has returned to at least somewhat below normal, Dr. Snyder said tapping on the roof of the corne- al tunnel will usually drop the iris back in with- out any direct contact. However, in stubborn cases, he said the iris can be pulled into the anterior chamber with microforceps through a paracentesis on the other side. Gently grasp the iris internally and pull it into the AC, he said. Dr. Snyder said pushing the iris with an instrument through the same wound as the prolapse is less effective and can cause more stromal or pigment loss. Finally, he said another strategy when there is minimal prolapse after the chamber is depres- surized is to use a gentle squirt of balanced salt solution external to the wound ostium. This can create an internally directed flow gradient and "blow" the iris in, he explained. There was less squeezing and posterior pressure from the patient at the start of the case. As he made the incision and inserted a little visco- elastic, the iris began to prolapse. He left the iris alone at this point, abandoned the original incision, and made a supero-temporal incision instead. He was able to phaco and put the lens in through this separate incision. This time he said he was able to sweep the iris back in with a blunt I/A tip. He said sometimes tapping on the roof of the incision can coax the iris back in when there is mild prolapse. Leela Raju, MD, on the panel for the ses- sion, told Dr. Rao that switching to the other wound was a great idea. "It feels like you're failing but you're not; you're making it easier for yourself," she said. How to prevent iris prolapse Whenever an eye is at risk for iris prolapse, Dr. Snyder said to stop irrigation and let the chamber shallow before removing the phaco or I/A tip. While this might sound counterintuitive, especially in shallow chambers, he said that if there is no pressure gradient for flow to occur out of the wound, the iris will not follow if there is no flow. Other advice Dr. Snyder gave was to make sure the wound is carefully constructed with a slightly more anterior internal entry into the chamber and a longer tunnel. He also advised intravenous mannitol preop in eyes with short axial lengths and mentioned use of iris hooks to dilate and stabilize the pupil with one hook under or adjacent to the wound, which was described by Thomas Oetting, MD. 1 "If the iris is tethered internally peripheral to and under the wound, it cannot prolapse out," Dr. Snyder said. @MyASCRS @ascrsofficial American Society of Cataract and Refractive Surgery @ASCRStweets Continue the conversation Share on ASCRS social platforms your tips/pearls for handling iris prolapse.

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