Eyeworld

EW CATARACT 39 When first learning to place the rings, Dr. Crandall said it's helpful to use a small amount of viscoelas- tic underneath the iris. This creates space between the iris and lens at each of the points where the loops of the ring will be. "The far loop is the easiest to engage with the iris. Once that is in place, as I'm injecting the lens, I'll rotate the superior and inferior loops to catch the iris. I'll use an Osher/ Malyugin Manipulator to place the subincisional loop," he said. Dr. Weber also backed the trick of using a cohesive viscoelastic to create space in the nasal ciliary sulcus, tenting up the iris away from the anterior lens capsule. From there, he tries to engage the lateral ring scrolls first, but if he can't, he'll engage all of the remaining scrolls after fully inserting the ring with a manipulator. When it comes to removal, Dr. Crandall said he disengages the far loop first, then unhooks the supe- rior and inferior loops, pushing the whole ring away to disengage the subincisional loop. "I like to get the distal (usually nasal) loop first because sometimes that loop will slide underneath the iris rather than on top of it. It is much easier to retrieve from across the eye than from the subincision- al area," he said. "I then slide the manipulator under a loop and pull it out through the main incision. By moving my hand to the right as I take the ring in, the loops will slide out one at a time. For me, this has been more efficient than using the ring injector to remove the device." "To remove the ring, I first disengage the distal scroll and then disengage the proximal scroll and deliver it from the anterior chamber through the wound," Dr. Weber said of his technique. "Delivering the scroll in this way allows for simple grasping with the inserter and com- plete withdrawal from the eye." Dr. Crandall said he always uses the 6.25 mm ring, finding it gives him enough room to work while being easier to insert than the 7 mm size. He'll use the latter if he's concerned about the pupil coming down during surgery. Similarly, Dr. Weber said he'll use the larger ring in cases with higher degrees of IFIS. If he decides to use hooks, Dr. Crandall makes his paracentesis just large enough and perpendicular to the peripheral cornea so the hooks are pointed downward into the anterior chamber. If these are made parallel to the iris, they would tent it up, making everything else more difficult. "I place each of the hooks I'm using into the incisions and just catch the edge of the iris," Dr. Crandall said, noting that he uses a square pattern. "Once all of the hooks are in, I'll tighten each one to get the pupil size I want. I avoid over tightening these to minimize trauma to the iris sphincter; I get the pupil large enough for me to comfortably proceed with the rest of the case. "If I am dealing with a very flop- py iris and iris prolapse, then I will also place a hook subincisionally," he added. To remove, Dr. Crandall said he'll loosen them enough to disen- gage from the iris. Then he will turn the hook sideways and pull it out through the paracentesis. Dr. Weber said it's important to have phaco settings available for IFIS or know what changes to make in fluidics for these cases. "It is fairly rare for me to use a ring or hooks thanks to smart fluidics and lidocaine with epi- nephrine," Dr. Weber said. "Don't be afraid to change tactics and use the multiple tools at our disposal —change out a ring for hooks, if necessary, and don't forget about that fifth hook." EW References 1. Ratra V, et al. Small pupil – big problem: A management algorithm. Asia Pac J Ophthal- mol (Phila). 2015;4:131–3. 2. Hovanesian JA, et al. Intracameral phenyl- ephrine and ketorolac during cataract surgery to maintain intraoperative mydriasis and reduce postoperative ocular pain: Integrated results from 2 pivotal phase 3 studies. J Cataract Refract Surg. 2015;41:2060–8. Editors' note: Dr. Crandall and Dr. Weber have no financial interests related to their comments. Contact information Crandall: dackakarot@hotmail.com Weber: charles.weber@gmail.com The basics continued from page 37

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