Eyeworld

EW FEATURE 104 Challenging and complicated cataract surgery • October 2016 Managing continued from page 103 Before and after insertion of a Malyugin ring. The concentration of the phenylephrine/lidocaine combination Dr. Greenwood uses is phenylephrine 1.5% /lidocaine 1.0%. Both are preservative- and bisulfite-free. Source: Michael Greenwood, MD phenylephrine and 1% lidocaine if necessary. "Then I use the Malyugin ring if I'm not able to get them adequately dilated with the phenyl/lido mix and the viscoelastic," he said. Dr. Greenwood estimates that 10% to 20% of his IFIS cases require use of the Malyugin ring. Dr. Greenwood recommends surgeons have a low threshold for the use of mixes like phenyl/lido or a Malyugin ring. "When think- ing about if you should use it, if it crosses your mind, the answer is yes. I've never regretted putting a device in the eye, but there's always a time when you wish you put one in and you didn't," he said. Dr. Samuelson has a low thresh- old for using pupil expanders if a patient is at risk for IFIS. He also uses lidocaine with epinephrine, especial- ly when there are other risk factors, such as exfoliation syndrome or a particularly dense lens nucleus. As a glaucoma surgeon, he does a good deal of cataract surgery in patients who have exfoliation syndrome. "In general, I simply tolerate moderately small pupils or use expanders only if it is 4 mm or less," he said. Management of small pupil- related IFIS does not require any change in IOL use. These surgeons said the IOL selection process con- tinues as normal. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Condon: garrycondon@gmail.com Greenwood: Michael.greenwood@vancethompsonvision. com Samuelson: twsamuelson@mneye.com for better Malyugin ring management Tips • When inserting the ring in the eye, engage the scroll farthest away from you first and then the two side ones. • Recenter the device so when you make the rhexis, it's centered on the patient's visual axis. • Use a second instrument to remove the ring, such as the Malyugin manipulator. Unhook the distal side first, and work your way around in a circle. Be careful not to take any iris tissue. • You can also grasp the ring with any type of forceps or the manipulator. However, make sure it doesn't get caught on any tissue inside the eye as you bring it to the outside. Do this step before you remove the OVD. Source: Michael Greenwood, MD

• Cover