Eyeworld

EW CATARACT 26 May 2018 YES connect by Liz Hillman EyeWorld Senior Staff Writer How to prevent iris prolapse and what to do if it happens T oo often, people think of iris prolapse as synony- mous with intraoperative floppy iris syndrome (IFIS), but iris prolapse is its own differential diagnosis, said Eliza- beth Yeu, MD, assistant professor, Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia. "When we think of iris pro- lapse, there are certain risk factors that make someone predisposed," Dr. Yeu said. IFIS is arguably the biggest risk factor for iris prolapse. David F. Chang, MD, clinical professor, Uni- versity of California, San Francisco, and co-chair of the ASCRS Foun- dation, said that in addition to a history of systemic alpha antagonist medications, prior use of these drugs can also cause IFIS and may not be mentioned by patients. Leela Raju, MD, clinical associate professor, De- partment of Ophthalmology, New York University Langone Health, New York, said she will also look for iris atrophy in the other eye, if it has had surgery, which could suggest the potential for floppy iris. She said the preoperative signs of pseudo- exfoliation, such as deposits on the lens or a "moth-eaten" edge of the pupil sphincter, which could suggest poor sphincter tone, or poor dila- tion in the office, could be warning signs for iris issues intraoperatively. There are also a few intraop- erative situations that could create conditions for iris prolapse. Dr. Yeu said these include too much oph- thalmic viscoelastic device (OVD) in the eye, too much pressure coming posteriorly, or too wide or too short incisions. As soon as she starts a case, especially in shallow eyes (those 21 mm or smaller), Dr. Yeu presses down on the cornea to assess the pressure. After she creates her para- centesis, she watches how the iris behaves when she injects epineph- rine and lidocaine. If the iris seems to flutter more, it could indicate a floppy iris. She also observes iris be- havior when injecting viscoelastic. Ins and outs of iris prolapse I ris prolapse during cataract surgery can be challenging to deal with for new and experienced surgeons alike. In this month's "YES connect" column, Elizabeth Yeu, MD, David F. Chang, MD, and Leela Raju, MD, explain how to readily identify the risk factors for iris prolapse and share sev- eral intraoperative strategies for managing prolapse. The bulk of their advice, however, focuses on sound operative techniques that should be employed to help prevent prolapse. Fundamentally, iris prolapse is related to one of three things: (1) the wound (loca- tion, length, and relative size); (2) inherent iris tissue integrity (influenced by floppy iris syndrome, pseudoexfoliation); and (3) pressure gradients within both the anterior and posterior chambers. Avoiding rapid changes in pressure is critical in preventing iris prolapse, which is why young surgeons should learn to go in and out of the eye with irrigation off. In spite of a well-exe- cuted technique, prolapse will occasionally happen, and our experts have eloquently outlined methods to reposit the iris, steps that every surgeon should master. Zachary Zavodni, MD, YES connect co-editor The top image shows iris prolapse via the incision during a miLOOP (Iantech, Reno, Nevada) case. The iris was reposited with OVD (middle image), and a subincisional iris retractor (bottom image) was placed prior to inserting the phaco handpiece to prevent reprolapse. Source: David F. Chang, MD

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