Post on 23-Feb-2016
description
“Evaluation of Use of Pupil Expansion Device in Resident-Performed Phacoemulsification Surgery”
The authors have no financial interest in the subject matter of this e-poster.
Jennifer H. Hung, MDKristiana D. Neff, MD
Department of OphthalmologyUniversity of South Carolina,
Columbia, SC
BackgroundIntraoperative floppy iris syndrome (IFIS) is a
recognized triad composed of:1) billowing of a flaccid iris stroma2) progressive intraoperative pupil constriction3) propensity for iris prolapse.1,2,3
Strategies to minimize intraoperative complications associated with IFIS include the Malyugin ring pupil expansion device
The Malyugin ring has not been evaluated in the hands of resident surgeons, even though a small pupil may be the most common challenging feature in resident phacoemulsification.4,5
PurposeTo evaluate the use of the Malyugin pupil
expansion device in patients who underwent resident-performed phacoemulsification cataract surgery at one surgical center
Correct positioning of all eyelets of Malyugin ring using injector
To describe intraoperative and postoperative complications encountered during early resident use
MethodsRetrospective chart review of all patients who
underwent phacoemulsification surgery at one surgical center from August 2009 to August 2010
Inclusion criteria:1) resident-performed phacoemulsification2) use of Malyugin ring intraoperatively3) complete documentation of intraoperative
note and postoperative ophthalmic examinations. Included 43 eyes of 36 male patients
MethodsIntraoperative problems with the Malyugin
ring and signs of IFIS were noted.Postoperative best corrected visual acuity
(BCVA), complications and iris abnormalities (transillumination defects, iris stromal atrophy or irregular pupil) were recorded.
Postoperative BCVA was the best visual acuity recorded within 90 days of surgery.
Results
One or more eyelets snagged on the retractable injector hook during removal in 5 eyes
Dislocation of one or more eyelets requiring repositioning occurred in 2 eyes
ResultsIris incarceration by the
trailing eyelet during removal occurred in 1 eye. Of note, the Malyugin ring was removed using 0.12 forceps, not the injector, in this case.
ResultsPostoperative sequelae:
Iris stromal atrophy (3 eyes)Transillumination defects (2 eyes)Pupillary irregularity (1 eye) Cystoid macular edema (1 eye)
Responded to treatment with prednisolone acetate and diclofenac
There were no cases of extended or excessive iridocyclitis or pigment dispersion.
Postoperative BCVA was 20/30 or better in all eyes (except for 2 patients with prior retinal pathology)
Discussion of ComplicationsIntraoperative Complication Suggested improvementsDislocation/slippage of eyelets May occur more commonly with
6.25mm Malyugin ring. May require use of 7mm Malyugin ring
Iris incarceration resulting in hyphema, iridodialysis , or stromal loss
Ensure iris is fully disengaged from all 4 eyelets before withdrawing
Snagging of eyelet(s) upon retraction with injector hook
Assist/guide complete retraction of Malyugin ring into injector with second instrument vs partial retraction of Malyugin ring before removal6
Twisting/contortion of the Malyugin ring if snagging of eyelet has occurred with continued retraction
Partial re-injection of Malyugin ring into anterior chamber and assist/guide retraction into injector with second instrument as above
Continued iris prolapse during case
Ensure good wound architecture
DiscussionUnderstanding potential complications of
Malyugin ring use is critical for safe usagePostoperative sequelae include
transillumination defects, mild pupillary irregularities and stromal atrophy
Due to the learning curve, practicing placement and removal of the device in a wet-lab setting prior to initial patient use is recommended for resident surgeons
ConclusionsWith practice and an understanding of
potential complications, the Malyugin ring is safe and effective for use by resident surgeons.
Caution is needed in proper placement and removal of the ring to ensure good postoperative outcomes and low complication rates, especially when first gaining experience with the device.
References1. Chang DF. Use of Malyugin pupil expansion device for intraoperative floppy-
iris syndrome: results in 30 consecutive cases. J Cataract Refract Surg 2008; 34: 835-841.
2. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M. ASCRS White paper: clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2008; 34: 2153-2162.
3. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31: 664-673.
4. Ku TK, Rutar T, Han Y, Porco TC, Naseri A. Resident-performed phacoemulsification in tamsulosin-treated patients. Arch Ophthalmol 2010; 128(8): 967-972.
5. Rutar T, Porco TC, Naseri A. Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology 2009; 116: 431-436.
6. Rauen M, Oetting T. Partial retraction of Malyugin pupil expansion device to improve safety during ring removal. J Cataract Refract Surg 2010; 36(3): 522-523.