“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.