Eyeworld

103 EW FEATURE October 2016 • Challenging and complicated cataract surgery Intraoperative management The surgeons interviewed by EyeWorld take special steps to manage cataract surgery in patients affected by IFIS. Dr. Condon pre-treats the eye with a mixture of 0.025% epineph- rine and 0.75% lidocaine in fortified balanced salt solution—a combina- tion called Shugarcaine after the late Joel Shugar, MD, who devised the mix. The mixture is made in the OR in advance of surgery; the lido- caine relaxes the sphincter and the epinephrine stimulates the dilator muscle. If that does not work effective- ly, Dr. Condon adds a mechanical device. "If you're faced with a concerning case of potential IFIS, there is nothing more effective than a Malyugin ring," he said. Although there are other devices from which surgeons may choose, Dr. Condon EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put "EW Pulse" in the subject line. Poll size: 264 continued on page 104 In a patient who has used tamsulosin or other similar medications, "you may need to change the plan and insert pupil expanding devices on the fly, after the phaco has started." –Thomas Samuelson, MD favors the Malyugin ring because it can go in through the operating incision versus having to make four incisions. Some surgeons may be reluctant to use the Malyugin ring because they don't know how to properly insert it. Dr. Condon recommends practicing on patients who don't re- ally need it, so you feel ready when you do actually require it. Dr. Condon uses the Malyugin ring toward the beginning of a po- tential IFIS case but will use hooks if he is running into IFIS issues toward the middle of a case. For his surgical management, Dr. Greenwood uses preoperative pledgets with 10% phenylephrine, 1% tropicamide, 2% cyclogyl, and a nonsteroidal anti-inflammatory drug (NSAID). "Using the NSAID ahead of time stabilizes the iris more," Dr. Greenwood said. If the patient has decent dila- tion, Dr. Greenwood uses a disper- sive ophthalmic viscosurgical device (OVD) to complete the capsulorhex- is. Next, he will inject a mix of 1.5% After insertion of a Malyugin ring Source: Boris Malyugin, MD

• Cover