JUL 2013

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

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February 2011 July 2013 Cataract challenges EW FEATURE 35 Reversion of IFIS. Patient under treatment with tamsulosin who forgot to mention the intake of the drug. IFIS developed during phacoemulsification. Note the miosis and prolapse through the paracentesis and main incision. A decision was made to inject 0.6 cc of intracameral phenylephrine 1.5%, which caused the pupil to dilate back to its preoperative level, restored iris rigidity, and stopped the tendency of the iris to prolapse. This is a view of the pupil diameter at the end of the case, which reached its preoperative level. Intracameral mydriatic dilation. Pupil size at the beginning of surgery. No dilating drops were instilled. Pupil size after intracameral injection of 0.3 ml of lidocaine 2%; it remained stable throughout surgery. This is an image of the pupil size at the end of the case. Source (all): Ramon Lorente, MD Dr. Malyugin usually starts his surgery by injecting intracameral epinephrine or phenylephrine. "This strengthens the iris muscle and increases the rigidity of the iris tissue and also increases the diameter of the pupil," he said. "After that I judge whether or not posterior synechiae are present because sometimes when I'm able to dissect those I can free the pupil, which becomes wider, and there is no need for any pupil expansion devices." Femtosecond laser extracurriculars One other new approach is use of the femtosecond laser. In the United States it is strictly off label to use this on patients with small pupils, Dr. Culbertson said. If the pupil is too small the laser won't be able to soften or fragment the lens since it can't cut through the iris. However, since the femtosecond is potentially advantageous for many ancillary conditions that may also plague those with small pupils, such as weak zonules, some doctors have begun giving it a try. This has meant first expanding the pupil to make femtosecond use possible. "I know of some doctors who have put in one of the dilating solutions like Shugarcaine, phenylephrine, put in viscoelastic through a small incision, and opened the pupil," Dr. Culbertson said. They put in a Malyugin ring and swing the patient over to the femtosecond laser [to do] the capsulotomy, lens fragmentation and softening, and other incisions. Then they bring the patient back under the microscope for traditional phacoemulsification, he explained. Dr. Malyugin pointed to work done by Zoltan Nagy, MD, Budapest, who uses the femtosecond laser in tandem with the Malyugin ring. "After injecting the Malyugin ring, he removes viscoelastic from the anterior chamber because this can have some issues with the laser energy hitting the capsule, and then creates the capsulorhexis and nucleus fragmentation (with the femtosecond laser) and proceeds with the cataract procedure," Dr. Malyugin said. Overall, Dr. Culbertson is encouraged by recent improvements in small pupil cataract techniques. "Fifteen years ago, small pupil cases were problematic," he said. "Then we learned to stretch the pupil and started using hooks and rings to enlarge the pupil, as well as pharmacologic enlargement. I think that having to perform the operation while the pupil is small is uncommon with the technology and the techniques that have developed over the last 15 years." EW Editors' note: Dr. Culbertson has financial interests with OptiMedica (Sunnyvale, Calif.). Dr. Lorente has no financial interests related to this article. Dr. Malyugin has financial interests with MST. Contact information Culbertson: wculbertson@med.miami.edu Lorente: rlorenteoftal@yahoo.es Malyugin: boris.malyugin@gmail.com

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