FEB 2014

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

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Page 89 of 114

E W RESIDENTS 8 7 available from compounding phar- macies. Lorente et al. studied the efficacy of intracameral phenyle- p hrine 1.5% compared to control in cataract patients with a history of tamsulosin use. 2 In the control group that received no intraopera- tive phenylephrine, 88% showed signs of IFIS compared to 0% in the group receiving the intraoperative phenylephrine. In cases where the pupil does not dilate following injec- t ion of phenylephrine, Malyugin ring implantation should be consid- ered to mechanically maintain pupillary dilation during the rest of the case. I adopt an "if I consider it, I'm putting it in" approach with regard to Malyugin ring usage. Im- plantation and removal of the ring are easy skills to learn. Implantation o f the ring removes the stress of worrying about iris prolapse, allow- ing the surgeon to focus on the task at hand: efficient and safe removal of the cataract. In the case presented, I would first decide if the wound construc- tion was to blame for the prolapse. If the wound was made too wide, there will be too much egress of fluid during phacoemulsification due to a poor match between the wound width and the phaco sleeve diame- ter. In this case, I would consider closing the incision with a suture and placing a new, better con- structed incision elsewhere. If the wound diameter matched the phaco sleeve diameter, I would be less concerned about the short tunnel length being the cause of the iris prolapse. It is very important to learn early on in your training how to "float" your instruments in the wound and to not unnecessarily gape the wound with an instrument, which can lead to iris prolapse. An- other possible cause of iris prolapse in this case is overinflation of the anterior chamber with viscoelastic. A soft shell technique is my viscoelastic technique of choice: The initial injection of a dispersive viscoelastic coats the corneal en- dothelium and protects it through- out the case. The subsequent injection of cohesive viscoelastic pushes the dispersive up against the endothelium and improves visuali- zation and flattening of the anterior capsule during capsulorhexis cre- ation. With this technique, however, the surgeon must not use too much viscoelastic, particularly in cases at risk for iris prolapse as this will increase the pressure gradient and potential chance of iris prolapse. With particular attention to risk factors, warning signs, appropriate use of prophylaxis with mydriatic agents and/or mechanical pupil dila- tion, the incidence of intraoperative iris prolapse can be greatly reduced, t hus significantly lowering intraop- erative surgeon anxiety. EW References 1. Chang DF, Campbell JR, Colin J, Schweitzer C. Intraoperative Floppy Iris Syndrome Severity with Tamsulosin versus Alfuzosin. Ophthalmology 2014 e-pub:1-6. 2. Lorente R, de Rojas V, Vazquez de Parga P, Moreno C, Varela J, Landaluce ML, Mendez J, L orente B. Intracameral phenylephrine 1.5% for prophylaxis against intraoperative floppy iris syndrome: prospective, randomized fellow eye study. Ophthalmology 2012;110(10): 2053-8. Editors' note: Drs. Hamilton, Haripriya, and Sun have no financial interests related to the article. Contact information Hamilton: Hamilton@jsei.ucla.edu Haripriya: haripriya@aravind.org Sun: grs2003@med.cornell.edu Sponsored by ZEISS Cataract Suite: Designed to Work Together for Expert Outcomes 11:30 AM – 12:00 PM Registration and Lunch 12:00 – 1:00 PM Program Join our panel of experts as they discuss how the ZEISS Cataract Suite substantially improves workflow from the office through to the OR. Learn how the IOLMaster ® 500, CALLISTO eye ® and OPMI LUMERA ® 700 empower surgeons to achieve the expert outcomes patients expect. SUR.5976 Save the Date B O S T O N 2 014 Saturday, April 26 Westin Boston Waterfront Hotel Grand Ballroom (concourse level) 425 Summer Street – adjacent to the Boston Convention and Exhibition Center (Skybridge located on level 2 of convention center) Register now: www.EyeWorld.org/ meetings/Zeiss February 2014 84-90 Residents_EW February 2014-DL2_Layout 1 1/31/14 10:37 AM Page 87

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