Eyeworld

EW RESIDENTS July 2014 51 Kevin Denny, MD Chief, cataract and anterior segment surgery California Pacific Medical Center, San Francisco Given that this is a teaching exercise, it's reasonable to first ask whether this scenario might possibly have been avoided. The history of prior prostate surgery suggests a high likelihood of prior alpha- blocker use. So even if epinephrine and a Malyugin ring weren't employed in advance of miosis and billowing, there should be a low threshold for putting the case on "pause" and making an intraopera- tive correction, which might include intracameral epi, Healon5 (Abbott Medical Optics, Santa Ana, Calif.), iris control devices, and adjustment of the phaco machine parameters, particularly vacuum and aspiration flow rate. When operating with our resi- dents, I regularly call attention to the loss of visualization of the tip of the phaco needle within a nuclear piece. This is most dangerous when the lens nucleus is sufficiently dense that it doesn't "fold itself" into the tip as it does in so many of the "Masters of the Cataract Universe" videos. As we are told occurred in this case, the phaco needle can bore through the nuclear piece and break out the other side before the foot pedal is changed to irrigation only. This is how iris and posterior capsule can be inadvertently damaged, particularly when especially mobile with intraoperative floppy iris syn- drome (IFIS). The teaching points are to have both a high sense of awareness and an active second in- strument manipulating the impaled nucleus off the phaco needle and back onto the tip to achieve occlu- sion. Now that the iris injury has oc- curred with a substantial amount of the lens still in the eye, how can we bring this case to a successful out- come with a minimum of dyspepsia for resident and attending alike? I would add intracameral epi, "com- partmentalize" the iris and nuclear fragments with a dispersive OVD, and lower my phaco parameters. I would manipulate the nuclear pieces to the phaco tip and try to maintain occlusion as much as possible to avoid drawing the iris to the tip. If needed, two iris hooks could be used to move the damaged iris more peripherally. For the cortex, bimanual I/A can be exceedingly helpful by allowing the aspiration port to be placed directly against the cortical strands without the turbulence of the coax- ial irrigation. OVD removal can also be nicely done with the bimanual I/A and can allow the temporal wound to be closed with balanced salt solution or a suture beforehand and keep iris prolapse to a mini- mum. As with all difficult cases, prophylaxis of elevated pressure and inflammation should be considered and the patient more closely moni- tored postoperatively. A phone call to the patient that evening shows your interest and concern. Soosan Jacob, MS, FRCS, DNB Senior consultant ophthalmologist Dr. Agarwal's Eye Hospital, Chennai, India This is an interesting case as the complication has occurred with an operating surgeon who seems to have reasonably enough experience to be able to perform phaco un- eventfully. More importantly, the patient has a history of transurethral prostate surgery. It is very probable that prior to the prostatic surgery, he might also have been on medical management for the prostate hyper- trophy, likely with alpha 1A receptor antagonist (e.g., tamsulosin). It has been reported that permanent iris dilator muscle atrophy may result from drug accumulation in the iris pigment granules. In view of the past history, it is therefore possible that the sudden intraoperative miosis could have been part of IFIS as first described by Chang and Campbell. Mechanical stretching of the iris and sphincterotomies are contraindicated in IFIS as they worsen the condition. The frayed pupillary margin that occurred during surgery in this patient would behave similar to a mechani- cal stretch, and the resultant loss of tone of the iris would make the surgery more difficult even though this case did finally proceed un- eventfully. Cases such as this reinforce the importance of taking a thorough history and being more prepared. Preoperative evaluation of the extent of pupillary dilatation is im- portant as poor dilatation is a strong indicator for IFIS. Preoperative preparation with appropriate dilat- ing drops (phenylephrine, atropine) and topical NSAIDs help to maintain pupillary dilatation intraoperatively. Clear corneal incisions should be made anterior to the iris root to avoid iris prolapse. During surgery, intracameral epi-Shugarcaine may be used to increase iris rigidity by increasing iris dilator tone, and if required, high viscosity OVD such as Healon5 may be used to maintain space in the anterior chamber. However, once the iris is caught, there is a tendency for it to get caught again and again. This can cause further iris damage as well as progressive miosis. The phaco probe or the I/A probe should preferably not be taken close to the involved quadrant again. If this cannot be avoided, care should be taken to work well above or below the pupil- lary plane (as required), and high vacuum settings that can draw the frayed iris strands into the aspiration port should be avoided. Low flow parameters are preferable and intra- cameral fluid currents from the irri- gation port should be used to the surgeon's advantage. A blunt rod in the non-dominant hand can be used to hold the iris away. Low flow set- tings and decreased vacuum levels prevent recurrent pupillary capture in the probe and also help avoid the OVD from getting aspirated too soon. If required, mechanical pupil dilators such as iris hooks or a Malyugin ring may be used. Adopting a judicious mix of measures generally succeeds in completing the case uneventfully, and the resident is to be congratu- lated for having been able to handle this challenging situation successfully. EW Contact information Denny: kjdenny1@aol.com Jacob: dr_soosanj@hotmail.com Sikder: ssikder1@jhmi.edu "As with all difficult cases, prophylaxis of elevated pressure and inflammation should be considered and the patient more closely monitored postoperatively. A phone call to the patient that evening shows your interest and concern. " 50-53 Residents_EW July 2014-DL_Layout 1 6/30/14 8:49 AM Page 51

• Cover