Eyeworld

66 | EYEWORLD | SPRING 2025 ATARACT C up the surgery, but if you have the pupil con- tracting against a Malyugin ring, it's going to be more taut. It may make it less floppy," he said. Another option Dr. Meghpara offered, if the iris keeps prolapsing out, to avoid damaging the tissue, is to leave it out of the wound, finish the cataract portion of the case, and sweep the iris back into the eye at the end of the case. "It's out of the eye but at least you're ma- nipulating it less. That's the last-ditch effort to finish the case because every time you touch it, you're creating defects in the iris and you could have a bigger issue after the fact trying to repair that," he said. Postop, if there are not significant iris defects caused by the prolapse and subsequent manipulation to get it back into the eye, the pa- tient should not experience any issues. If there are significant iris defects, both Dr. Tipperman and Dr. Meghpara said they tell the patient that the case was difficult and that if they experience visual disturbances due to the iris defect, they can fix it. Dr. Meghpara added that with the extra manipulation in these cases, patients who expe- rienced iris prolapse can be more prone to CME, so he advised an NSAID postop. Contact Meghpara: bmeghpara@willseye.org Tipperman: rtipperman@mindspring.com Relevant disclosures Meghpara: None Tipperman: None Dr. Tipperman said when the iris keeps coming out of the main incision due to wound construction, one option is to place a sheets glide through the incision over the iris to push it back and protect it from the phaco. Another option is to sweep the iris back in, suture the incision, and move a few clock hours away. The latter, he said, takes a little bit more time, but it makes the case easier in the long run. Dr. Meghpara said when prolapse occurs, "don't panic." "You don't want to turn something that is fairly easy to manage, do the wrong things, and turn it into a much bigger situation," he said. "The first thing is avoid trying to push it back in or trying to fill up the anterior chamber with more viscoelastic to push it back in. You want to decrease the pressure in the anterior chamber. The way you do that is you shallow it through a paracentesis; try not to touch the iris as your first reaction." Once the pressure is lower, he said to use a blunt instrument through a paracentesis to sweep the iris back into the eye. "We're not pushing it in but sweeping it from inside and sweeping it out of the incision back into the anterior chamber," he explained. After one prolapse, Dr. Meghpara said the iris tends to want to do it again, so he'll adjust his phaco settings to low flow, decreasing the bottle height and lowering the vacuum and as- piration rates so there is less fluid going behind the iris. "Sometimes once you get it in the eye, you can put a very small amount of high viscosity viscoelastic on top of the iris by the incision to push it backward. You don't want to overfill the anterior chamber with viscoelastic completely because then you'll prolapse out again because you've created too much pressure in the anterior chamber, but a very selective amount right in the area of prolapse will help," he said. If it keeps prolapsing out despite these efforts, Dr. Meghpara will employ iris hooks (usually four in a diamond shape to keep the iris taut) or a Malyugin ring. "What you can also try to do is put in iris hooks or the Malyugin ring and constrict the pupil, with an intracamer- al miotic. … You need the pupil dilated to finish continued from page 65 Marisa Schoen, MD, Wills Eye Hospital, presented a case at the 2024 ASCRS Annual Meeting that Dr. Tipperman called "a neat trick." In this video she takes an iris hook, makes an incision in the sclera posterior to the main incision, and hooks the pro- lapsed iris, pulling it out of the way. Watch the video!

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