October 2020


My Worst Complication
Unruly iris during cataract surgery

by Liz Hillman Editorial Co-Director

This intraoperative photo shows mild iris prolapse into the incision before all of the cortex was removed.

Iris prolapse occurred during an IOL exchange. Kevin Miller, MD, said he was just getting ready to remove a Malyugin ring at the point captured in this image. You can see mild iris atrophy in addition to prolapse.
Source (all): Kevin Miller, MD

This direct illumination photo shows severe temporal iris trauma from intraoperative iris prolapse during cataract surgery in a patient who was referred to Kevin Miller, MD.

This higher magnification retroillumination photo of a patient referred to Dr. Miller with severe temporal iris trauma from intraoperative iris prolapse shows that the edge of the optic and opacified peripheral capsule are visible behind the iris defect. The patient had severe light and glare sensitivity under all lighting conditions.
Source (all): Kevin Miller, MD

“It’s very important to be prepared to be able suture the iris. Rarely used skills like this can so easily be practiced now with the excellent simulated eyes we have in our own ORs, using our own instruments without any special wet lab.”
—Thomas Oetting, MD

Iris prolapse into phaco and/or sideport incisions or trauma from it getting caught in the phaco needle is a complication that is most commonly associated with intraoperative floppy iris syndrome (IFIS). Intraoperatively, too small or too wide of an incision, use of too much ophthalmic viscoelastic device, and/or too much pressure can contribute to cases of iris prolapse or trauma.

‘This is a skill to practice’

It was 2010 and Thomas Oetting, MD, was supervising his chief resident at the time on a cataract case. The patient was on tamsulosin.
“This is an example of bad things aligning to cause a problem,” Dr. Oetting said of the case.
They had used intracameral epinephrine to keep the pupil, for the most part, large enough to create the capsulorhexis and allow for lens removal without hooks or rings, he said.
“However, just with the last piece of nuclear material, the patient moved a bit as the surgeon came more anterior to get a piece in the subincisional area and bam! As the piece was removed, the tip caught the iris and caused significant damage,” Dr. Oetting said.
The surgeon was able to remove the remaining cortical material and place the IOL without further damage, followed by two sliding Siepser, 10-0 Prolene sutures with a CTC6L needle to close the defect.
“This is a skill to practice before something like this happens, and I would suggest using artificial eyes,” Dr. Oetting said, citing Phillips Studio eyes, Bioniko, Kitaro (Frontier Vision), and SimulEYE (InsEYEt) as options.
“It’s very important to be prepared to be able suture the iris,” he said. “Rarely used skills like this can so easily be practiced now with the excellent simulated eyes we have in our own ORs (as there is no cadaver or animal products), using our own instruments without any special wet lab.”
The patient did well postop with a little glare but otherwise “excellent return of visual function,” Dr. Oetting said.

‘Time and again, the iris comes into the phaco tip’

Manish Mahendra, MD, described in a 2019 ASCRS Annual Meeting video how iris prolapse occurred during hydrodissection on a patient where he was unaware of prior tamsulosin use. This slight bulge of iris tissue was put back in easily, but as the case progressed, the iris constricted, and at one point, iris moved into the phaco tip.
“As I tried to take my nuclear pieces, time and again the iris comes into the phaco tip,” he said.
With continued floppiness impacting the surgery, Dr. Mahendra inserted a Malyugin ring, finding phaco thereafter much easier. However, despite the Malyugin ring, iris prolapsed again through the sideport and the main incision.
To prevent this situation, Dr. Mahendra said preoperatively to be aware of alpha blockers in the medical history and discontinue them ahead of surgery, prescribe atropine and reduce IOP.
“However, tamsulosin and other alpha blockers have long half-lives and remain in the anterior chamber as long as 28 days. Also, alpha blockers cause ultrastructural changes in the iris stroma leading to its functional loss even after discontinuation of the drug,” Dr. Mahendra said.
Intraoperatively, Dr. Mahendra said a MICS technique should be used, with a long, watertight main incision and sideport. Intracameral epinephrine and viscomydriasis can be used to maintain an adequate pupil size along with iris hooks and pupil expanders. Exercise restraint when hydrodissecting and carefully adjust fluidics during the case, Dr. Mahendra said.

At a glance

• Iris prolapse or iris trauma in the phaco tip is often associated with IFIS, too small or too wide of an incision, too much OVD, and/or too much pressure.
• Physicians said to be careful of the last piece of nuclear material, after which the iris, due to the change of fluidics in the eye, might come toward the phaco tip.
• It is important to be prepared to suture the iris in case of trauma; practice with a simulation eye.

About the doctors

Manish Mahendra, MD

Khairabad Eye Hospital and Mahendra Eye Institute
Kanpur, India

Thomas Oetting, MD
Rodolfo N. Perez Jr., MD, and Margaret Perez Professor in Ophthalmology Education
University of Iowa
Iowa City, Iowa

Relevant disclosures

: None
Mahendra: None


: thomas-oetting@uiowa.edu
Mahendra: drmanishmahendra@gmail.com

Recovering mentally from complications

Uday Devgan, MD, Clinical Professor of Ophthalmology at UCLA, Los Angeles, California, shared a resident’s case video. To start, the resident surgeon was operating with an open posterior capsule and was, at times, losing pieces of the nucleus into the vitreous. The patient was going to need a pars plana vitrectomy and lensectomy.
The first thing to do is “accept that you’ve had a complication and avoid denial. … Two, recover now and minimize the iatrogenic trauma.” Step three is to advocate for your patient. “There was a complication, whether it was an iatrogenic issue or the patient had bad tissue, and now you have to be your patient’s advocate to help them recover. You need to be able to ask for help. … There is no harm in asking for help, in fact, it is the right thing to do. Your patients will appreciate it.”
Dr. Devgan said it’s important to take a breath, compose yourself, acknowledge the complication, decide how to best handle it, and be prepared to move on to the next case.
“It’s important that you give 100% of your energy, your focus to the next patient. Most of us do many surgeries in a single day. If you have 10 surgeries lined up for the day and you have a complication on patient number three, understand that it’s going to take you longer to fix that complication, so now the rest of the patients are going to be delayed. That’s OK; give the time that the patient needs and for you to recover that complication. Also, you need to have your mind back in the game, your mind refocused so the patients in your surgical lineup are going to have your best efforts. You can’t dwell on what’s already happened.”
Despite the extra surgeries that were needed in the case that Dr. Devgan used to highlight his point about mentally handling complications, he said the patient ended up doing great.
Dr. Devgan’s steps for overcoming complications are:
1. Accept that there was a complication. Avoid denial.
2. Recover from the complication. Minimize iatrogenic trauma.
3. Be an advocate for your patient. Explain what happened postoperatively and ask for help when you need it.
4. Refocus, compartmentalize so you can give 100% of your effort to your next patient.
Watch Dr. Devgan’s video at bit.ly/326asfw.

Relevant disclosures

Devgan: CataractCoach.com


Devgan: Devgan@gmail.com

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