DEC 2013

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

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20 EW CATARACT December 2013 Tools & techniques Managing iris prolapse when sealing the wound during cataract surgery by Daniel H. Chang, MD H oward Fine, MD, has taught me to treat every small pupil case as an IFIS case. When I first heard his tenet, I was of course skeptical—I am by nature a doubter. With experience, observation, and many frustrating intraoperative moments, I have come to appreciate his wisdom in regard to the small pupil. I have seen numerous cataract cases with what appears to be adequate 5-6 mm pupils turn into nasty whirlwinds of distress and iris transillumination in patients who for the most part have no pharmacologic risk factors for IFIS. Using a biaxial technique and a pupil expansion device in these borderline dilators has for the most part eliminated the development of floppy irises until after viscoelastic removal, following removal of the pupil ring or hooks. In this month's column, Daniel H. Chang, MD, provides a succinct overview of the fluidics of iris prolapse. He gives several useful tips for both preventing iris prolapse and repositioning the prolapsed iris with minimal tissue trauma. It's a quick read and very useful for maximizing outcomes in the floppy iris patient. F ew things are more frustrating during cataract surgery than iris prolapsing into the wound. Various surgical devices—including iris hooks, iris rings, and viscoelastics— can help to manage the iris during the procedure. However, none of these devices can be utilized at the end of the case, when the wound is being sealed with stromal hydration. Intended to seal the wound, stromal hydration can create a high-flow state that actually elicits iris prolapse (Figure 1). To develop a strategy for managing iris prolapse, it is important to understand the fluidics that cause this complication. Because of Bernoulli's principle, rapid fluid egress from a wound creates a negative pressure gradient that draws iris into the wound and out of the eye. Iris goes where fluid flows, so man- aging the fluidics can manage the iris. By reducing the pressure gradient across the wound, fluid flow is reduced, and cases of prolapsing iris can be remedied without poking, sweeping, or otherwise touching the iris. This can be achieved through four simple techniques. 1. In cases at risk for iris prolapse (e.g., in an eye with intraoperative floppy iris syndrome), if the I/A tip is withdrawn rapidly, the Figure 1: Iris prolapse Figure 2: Stop irrigation and soften the eye prior to withdrawal of I/A tip. Note the corneal striae in a soft eye. Figure 3: Tap the paracentesis port. Figure 4: Press on the anterior lip of the wound. Richard Hoffman, MD, Tools & techniques editor Figure 5: Tangentially hydrate the stroma. Source (all): Daniel H. Chang, MD

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