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97 EW GLAUCOMA September 2016 Reference 1. Jasien JV, et al. Intraocular pressure rise in subjects with and without glaucoma during four common yoga positions. PLoS One. 2015;10:e0144505. mm Hg in glaucoma patients and 18 to 26 mm Hg in normal individuals. For glaucoma patients in plow pose, pressures went from a mean of 18 mm Hg up to 24, while for normal individuals this rose from 18 to 22 mm Hg. Finally, for the legs-up-the- wall pose, this went from a mean of 17 to 21 mm Hg in both glaucoma patients and normal individuals. Within 2 minutes of assuming a sitting position, IOPs dropped back to baseline pressures. "There was no real difference in patients with and without glaucoma," Dr. Ritch said. "Once they sat up, the pressure came down." The fact that each of the yoga poses is only held for 2 minutes and not 20 bodes well for those with- out glaucoma. "If they don't have glaucoma, presumably they're not doing any damage," Dr. Ritch said, adding that there is no indication that doing downward-facing dog for 2 minutes a day is going to cause glaucoma. However, for those who already have glaucoma, it may be a different issue. While determining this would require a prospective study, he thinks such positions should likely be avoided by some. "If patients have severe glaucoma, they probably should not be doing this," Dr. Ritch said. "If it's mild, they can do it but should get their visual fields checked periodically." He also thinks that doing Valsalva maneuvers common in some forms of exercise as well as while playing some instruments, such as a trumpet, tuba, or French horn, can push up IOP in glaucoma patients. He had one patient who had already lost vision in one eye to glaucoma and who had a tiny field remaining in the other. Because of a Valsalva maneuver, he lost his remaining sight in the middle of doing a sit-up. "We tested him doing a crunch and his pressure went from 12 to 30," Dr. Ritch said, adding that he had other patients with visual field loss who did push-ups. When he tested one, he found his pressure went from around 13 up to 27. Given the latest study, Dr. Ritch advises those with glaucoma to be wary of maneuvers in which the head is down. "If you have glauco- ma, watch out for positional chang- es where you have your head upside down," he said. "If you have severe glaucoma, be careful." EW Editors' note: Dr. Ritch has no financial interests related to his comments. Contact information Ritch: ritchmd@earthlink.net The OASIS IRIS EXPANDER (OASIS Medical) is a molded poly- propylene ring that expands the pupil and maintains access and visibility throughout the surgical procedure. The pupillary expansion device's four pockets gently cradle the iris rim without pinching or clamping. Once the expander is removed, the iris returns to its normal shape and function. I have been using the OASIS IRIS EXPANDER for 3 years. I use it for small pupils that will not dilate well for cataract surgery and for patients with intraoperative floppy iris syndrome, which can manifest as an adverse reaction to some medications. I prefer to use these iris expanders because they go through the main inci- sion and they are less expensive than other expanders. There is a small learning curve when first using the OASIS IRIS EXPANDER, but after the first few uses it becomes routine. The device is simple and safe to remove at the end of the procedure, which I see as an advantage. When first learning to use this device, I recommend insertion for a pupil that is not too small, perhaps 4 mm or so. Do not try catching the iris in the pockets during initial insertion, simply insert and float the device on top of the iris. Then, I start by placing each of the four pockets, or corners, beginning with the corner closest to me and then going counter-clockwise until all four corners are in place. I use a lens manipulator to put each corner in place, and I always make sure the manipulator is positioned 90° straight up and down so that I can easily remove it from the positioning hole. Postoperatively, I often increase the patient's steroids for several days because any manipulation of the iris can cause an inflammatory response. This article presents two cases in which I used the OASIS IRIS EXPANDER. CASE NO. 1 I performed cataract surgery on a 64-year-old woman with a small pupil (about 2 mm) who had anterior synechiae. The pupil would not dilate, so to perform the surgery I attempted to free her pupil from the anterior capsule with viscoelastic. However, her pupil still would not dilate. At that point, I decided to use the OASIS IRIS EXPANDER. The device comes in two sizes. If patients have a very small pupil, I choose a 6.25-mm expander, and if they have a medium- sized pupil (about 4.5 mm or larger), I use a 7-mm expander. I do not want to stretch the pupil too much and risk tearing it. I only want to expand it enough so that visibility is sustained throughout the procedure. The patient did very well. The pupil stretched, and her pupillary margin did not tear. When the sur- gery was complete, her pupil was larger than 2 mm, but it was round and symmetrical. The iris expander provided sufficient visualization for me to perform the surgery. CASE NO. 2 This is an interesting case because the patient, a 56-year-old woman, started with a large pupil. I performed a femtosecond laser procedure on this patient, but by the time I moved her from the laser suite to the surgery suite, which took about 5 minutes, her pupil had decreased in size to 2 mm. I decided to use a 7-mm expander because of her previously large pupil. I also wanted to ensure that I did not catch the capsulorhexis with the pupillary expander. I like the OASIS IRIS EXPANDER because I can slip it into the anterior chamber and then catch one edge of the iris. The patient's iris was near the center of the pupil, so I knew I would not catch the capsule. When the first two pockets of the expander were in place, I moved the whole iris expander toward my incision to make sure I was engaging the iris' margin and that I would not tear the anterior capsule. It was simple to place the device without trapping the anterior capsule with the iris. The surgery was a success. Request more pupil expansion device information by contacting (844) 820-8940 or sending an email to customerservice@oasismedical.com. Article reprinted from the June 2016 issue of CRST. OASIS IRIS EXPANDER Using an iris expander for small pupil cases provides sufficient visualization to perform surgery. BY ADELAIDE PRIESTER, DO Adelaide Priester, DO ✦ surgeon at Better Vision Ahead in Tulsa, Oklahoma ✦ alpmiowa@earthlink.net V I S I T O A S I S ® A T A A O C H I C A G O | B O O T H 4 0 2 1 OASIS IRIS EXPANDER GENTLE & EFFECTIVE EXPANSION Available in 7.0mm and 6.25mm for an unimpeded view during complicated small pupil surgeries. SOFT SHIELD ® Collagen Corneal Shields For ocular surface protection. © 2016 OASIS Medical. SOFT SHIELD and OASIS IRIS EXPANDER are trademarks of OASIS Medical, Inc. 514 S. Vermont Ave, Glendora, CA 91741 For more information: www.oasismedical.com | 844-820-8940 A D V E R T O R I A L This insert was independently produced by OASIS Medical. EyeWorld magazine had no part in its production. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld magazine and ASCRS.

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