Eyeworld

64 | EYEWORLD | SPRING 2025 ATARACT C by Liz Hillman Editorial Co-Director About the physicians Beeran Meghpara, MD Co-Director of Refractive Surgery Wills Eye Hospital Philadelphia, Pennsylvania Richard Tipperman, MD Attending Surgeon Wills Eye Hospital Philadelphia, Pennsylvania blood thinners. When you're in a busy cataract practice, it's often hard to keep track of what the different medications are that a patient is taking that is on this ever-growing list." Dr. Tipperman said that even if a patient is not currently on tamsulosin but had taken it in the past, it could still affect their iris. "Some patients could have been on tamsu- losin 15 years ago for a month then stopped it. They forget that they were on it, but their iris will still act like they've been on it the entire time," Dr. Tipperman said. "Some patients come in for cataract surgery and they've been on tam- sulosin for some time, and they say, 'Should I stop it for my surgery?' but there is no benefit in stopping it. Some patients' irises on tamsulosin act completely normal and others very abnor- mal with a lot of iris prolapse." Dr. Tipperman said too shallow or too posterior of a phaco entry could entice iris pro- lapse, as could eyes with a smaller axial length or anterior chamber depth, according to Dr. Meghpara. "Even something as simple as a thin blue iris … if I see a thin or pale blue iris, that makes me worry a little bit," he said. Dr. Meghpara said poor dilation can clue surgeons into IFIS. "If they don't dilate well, that is also something that will get your radar up," he said. If you have a known IFIS case that could be at risk for iris prolapse, Dr. Meghpara said it's important to dilate the patient as much as you can ahead of time. He said if he's worried about proper dilation, he'll increase the phenylephrine dose to as high as 10%. He also said the patient could be started on an atropine drop 1–3 days preoperatively to improve dilation. "There have been reports of using a topical NSAID 1–3 days before surgery also helps improve dilation. Just [try to] get as much dilation as you can ahead of time," he advised. Maintaining that dilation intraoperatively can be achieved with intracameral injections of epinephrine or phenylephrine/ketorolac (Omidria, Rayner) in the irrigating solution. The latter, he said, is helpful if you have access to it from a coverage standpoint. Dr. Meghpara said it's important with some of these cases to place incisions a little more anterior and make them a bit longer to get them R egardless of surgical experience level, Richard Tipperman, MD, said iris prolapse is something that happens to all surgeons occasionally. As such, knowledge of the risk factors that could predispose a patient for iris prolapse, how to handle the event should it occur, and postop considerations are an important refresh from time to time. "There are a lot of different ways to manage it and mitigate it, but it is something that everyone will see on occasion, and one certainly needs to know how to manage," Dr. Tipperman said. Predisposition and prevention Both Dr. Tipperman and Beeran Meghpara, MD, cited intraoperative floppy iris syndrome (IFIS) as the most common risk factor that increases a patient's chance of iris prolapse during cataract surgery. There are a number of medications that can cause IFIS, they both said, and situations that can lead to iris prolapse, such as certain ocular anatomies, and wound construction. Medications include most notably tamsulosin/ alpha blockers, though Dr. Meghpara said other medications can contribute to IFIS. "The list keeps growing and growing," Dr. Meghpara said of medications that can cause IFIS. "There are certain anti-psychotic medications that do it, certain blood pressure medications that have been reported, certain The iris prolapsed—don't panic Rom Kandavel, MD, EyeWorld Cataract Editorial Board member, shared what he is excited for at the ASCRS Annual Meeting: "My favorite part about the ASCRS Annual Meeting is walking away with that little nugget of information that makes a meaningful change in my practice. Sometimes it's clinical, sometimes it's administrative, but each time it makes a difference." ASCRS ANNUAL MEETING P R E V I E W

• Cover