Eyeworld

EW CATARACT 40 September 2017 by Robert Osher, MD Consequently, the device is easy to insert. I also find the new injector and the manipulator easy to use. I centered the Malyugin Ring, and after the lens was injected, I removed the ring. The sequence of ring removal is important, and there are two choices. In this case, I removed the OVD from behind the lens, and after injecting more OVD, I disengaged the distal scroll followed by the left and right scrolls. The most difficult scroll to disengage is the proximal scroll. To prevent it from rebounding under the incision, I push it centrally into the OVD and inject more OVD next to it. This fixes it, making it easy to go under the scroll with the manipulator, bring out the finger, and engage the scroll. I then introduced a second instrument through the side port to depress the right and left scrolls into the injector opening to ensure atrau- matic removal of the device. At the end of the procedure, the patient's pupil looked excellent. Case #2 This second case was a woman with mild Alzheimer's disease, very small pupils, and nanophthalmos. Intermittent compression of the globe against the bony orbit was performed to dehydrate the vitreous. The patient had previously under- gone a peripheral iridotomy for angle closure and had an anterior chamber depth of 1.5 mm. It has been said that it isn't possible to use a Malyugin Ring in these cases, but this isn't true. I created the necessary space using mannitol and intermit- tent compression of the globe. The iris was lifted off the anterior capsule with OVD, and the Malyugin Ring was inserted. I completed the capsu- lorhexis and hydrodissected the lens, at which point the patient became distressed and disoriented due to too much intravenous anesthesia. The anesthetist administered propofol, the patient became tranquil, and I was able to continue. I used a bevel-down phaco tip under Healon 5 and directed the energy backward until the trough was deep enough to turn the bevel up, and continued sculpting under a I have used the next-generation Malyugin Ring in many patients with great success and would like to highlight three cases. Case #1 This patient had superficial keratec- tomy for anterior basement mem- brane dystrophy and a long history of tamsulosin use with severe complications in the fellow eye due to IFIS. The patient was referred for surgery in the second eye. I raised the iris off the anterior capsule using Healon 5 (Johnson & Johnson Vision, Santa Ana, Cali- fornia); viscomydriasis added some dilatation. Through a second stab incision, I lifted the subincisional iris off the anterior capsule and placed the injector of the Malyugin Ring through a 2.2 mm incision and inserted the ring into the eye. The scrolls of the next-generation device are a little larger, which makes them easier to engage, and the ring is easier to compress due to the softer, more pliable 5-0 polypropylene. is placed through a main incision, thus eliminating the need for extra incisions. The Malyugin Ring has under- gone several modifications through- out its 9 years on the market. In 2015, I worked with MST to improve the Malyugin Ring injector. The Osher modification to the Malyu- gin Ring injector allowed for easier insertion and removal of the device. The classic Malyugin Ring design allowed for insertion through a 2.2 mm incision. Recently, MST has released the second-generation device, the Malyugin Ring 2.0. The Malyugin Ring 2.0 offers the same benefits as the classic version, but includes some added features. The next-generation device is made from 5-0 polypropylene (rather than 4-0 polypropylene), which is thinner and more flexible. The new design features a larger scroll gap that allows for easier engagement of the iris. The Malyugin Ring 2.0 injector was modified to fit through a 2.0 mm incision. How the new Malyugin Ring and injector help with small pupil cases S ince it was first introduced in September 2007, the Malyugin Ring (MicroSur- gical Technology, MST, Redmond, Washington) has set the standard of care for managing inadequate pupil dilation, which may occur in patients with conditions including chronic uveitis, intraoperative floppy iris syndrome (IFIS), glaucoma, pseudoexfoliation syndrome, diabetes mellitus, and idiopathic cases in the elderly. The original Malyugin Ring is a device made from 4-0 polypropylene with a scroll design that holds the iris and distributes outward force at eight equidistant points of con- tact. It is as or more effective than traditional pupil expansion devices (such as iris hooks), but causes less stress to the iris tissue and is easy to implant and remove. The device Experience with the next-generation Malyugin Ring Insertion of the Malyugin Ring Source: Robert Osher, MD

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