April 2010

 

CATARACT/ IOL

 

New indication of LIDRS


by Maxine Lipner Senior EyeWorld Contributing Editor 

   

Multifocal iris sphincter ruptures may signal complications

Age 65 years, dislocated PCIOL, PP vitrectomy: LIDRS is common in post-vitrectomy patients Source: Daljit Singh, M.D.

Multifocal iris sphincter ruptures may be a new sign alerting practitioners to cases involving lens-iris diaphragm retropulsion syndrome (LIDRS), according to Robert H. Osher, M.D., professor of ophthalmology, University of Cincinnati, and medical director emeritus, Cincinnati Eye Institute. In the January 10, 2010, issue of the Journal of Cataract and Refractive Surgery, Dr. Osher reported on a case in which such sphincter ruptures appeared to be associated with the condition.

LIDRS is commonly seen in two situations, highly myopic eyes and post-vitrectomy eyes. “When we put in infusions with the phaco tip or with the I & A tip, the chamber becomes extremely deep, the iris bows back, and as a result there is a big, hollow vitreous cavity,” Dr. Osher said. “When the iris bows back the pupil enlarges a great deal and almost gives the impression that the patient has aniridia, where there is no iris and the chamber deepens enormously.”

Spotting LIDRS syndrome

While some refer to this syndrome as LIDRS, others have dubbed it Infusion Deviation Syndrome. Dr. Osher said that these are the same condition. “You basically have a pupil block, where instead of blocking with the lens or the cornea, the iris blocks back against the anterior capsule,” he said. To treat the condition practitioners have two choices for repressurizing the eye and reestablishing normal chamber depth and hemodynamics inside the eye. “Some people like to lift the iris with an instrument, such as the tip of the phaco, the tip of the I & A, or with a second instrument,” Dr. Osher said. “I personally don’t like to touch the iris. I prefer to depress the anterior capsular rim.” Dr. Osher finds that both maneuvers accomplish the same thing—helping to equalize the pressure between the anterior and posterior chambers. “There’s a burst of fluid that breaks the block and enters the retro-iris space, and there is a neutralization of pressure gradients inside the eye and the chamber forms its normal depth.”

Recently Dr. Osher encountered a case involving LIDRS that he found to be particularly noteworthy. The case involved a 78-year-old highly myopic woman who while undergoing bilateral phacoemulsification developed a case of LIDRS. Dr. Osher found that during the surgery the anterior chamber became extremely deep and the pupil was excessively dilated, consistent with the syndrome. What made the case noteworthy was the occurrence of multifocal iris sphincter ruptures, which before had not been associated with the condition. “Normally, we see these multifocal sphincter ruptures after a pupil stretch technique where we take two instruments to stretch the small pupil deliberately to make it larger,” Dr. Osher said. “In this case, the stretch of the iris sphincter was so huge from having the iris driven back that it actually caused multiple sphincter ruptures.”

On alert for sphincter ruptures

Dr. Osher reported the case in the hope of alerting other practitioners to be on the lookout for such ruptures. He hopes this can forewarn them to be prepared for LIDRS when using phacoemulsification in the second eye. “There are ways to be ready for LIDRS,” he said. “You can reduce your bottle height and be prepared to use the maneuver of equalizing pressure by depressing the anterior capsular rim.”

He stresses that if practitioners see these multifocal sphincter ruptures in a patient’s first eye, perhaps in a case where they did not perform the initial cataract surgery, they should be prepared for a potential LIDRS case in the second eye. “If surgeons see sphincter ruptures, they can’t just assume that the patient had a small pupil that was stretched in the original cataract surgery,” Dr. Osher said. “Rather than make that false assumption, they should be prepared for an LIDRS situation in the second eye.”

Dr. Osher believes that it is helpful to remain on the alert for LIDRS. “This catches a lot of surgeons off guard. They’re used to working with a shallow chamber, a hyperopic eye perhaps, but they’re not used to working with extremely deep chambers,” he said. Such chambers can make the surgery much dicier. “Instead of phacoing in a plane parallel to the iris, you end up phacoing from the front to the back of the eye vertically,” Dr. Osher said. “That’s more dangerous.”

If not properly managed, LIDRS makes the surgery much more difficult. “I think that the capsule is more at risk because the phaco tips and I & A tips are not parallel to the floor, they’re basically headed back to the optic nerve,” Dr. Osher said. “Whenever the tips are vertical there’s more risk of breaking the capsule.” With proper management, however, LIDRS can be effectively handled. As for the patient in this case, she ultimately did very well. “She has some little sphincter ruptures that are permanent, but those are simply cosmetic,” Dr. Osher said.

Editors’ note: Dr. Osher has no financial interests related to his comments.

Contact information

Osher: 513-984-5133, rhosher@cincinnatieye.com

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