surgical strategies for small pupils - malyugin ring

Boris MalyuginS.FYODOROV EYE MICROSURGERY COMPLEX

MOSCOW, RUSSIA

MALYUGIN RING PEARLS

WHAT IS THE CRITICAL DIAMETER

FOR THE PUPIL

TO BE CONSIDERED “SMALL”?

S. Fyodorov Eye Microsurgery Complex Federal State Institution, Moscow, Russia


4.0 mm3.0 mm2.0 mm

SMALL PUPIL ???

PUPIL SIZE IS RELATIVE

TO:


SURGEON’S SKILL AND TECHNIQUE

INTRAOPERATIVE SITUATION

IRIS TISSUE PROPERTIES

MOST COMMON MECHANISMS

OF SMALL PUPIL FORMATION


ETIOLOGY MECHANISM

AGE-RELATED

PEX

IFIS

DIABETES

POST. SYNECHIAE

IRIS ATROPHY

IRIS DILATOR AND SPHINCTER MUSCLES ATROPHY

DILATOR MUSCLE ATONY-ATROPHY

METABOLIC CHANGES, RUBEOSIS

UVEITIS, ANGLE CLOSURE GLAUCOMA, PREVIOUS SURGERY

SURGEON’S SKILL & TECHNIQUE


USE VISCOADAPTIVE OVDs

DECREASE FLUIDIC

PARAMETERS

UTILIZE CHOP

MANIPULATE IN THE AC

CENTER

USE BIMANUAL IA

TECHNICAL CHALLENGES

OF SMALL PUPIL PHACO SURGERY

REDUCED RED REFLEX

INCREASED RISK OF IRIS DAMAGE

IRIS BLEEDING

IRIS PROLAPSE FROM WOUND(S)

SMALL ANTERIOR CAPSULORHEXIS SIZE

- ANTERIOR CAPSULE DAMAGE (CHOPPER, US TIP)

- HIGHER RISK OF POSTOP CAPSULAR PHYMOSIS

INCOMPLETE EVACUATION OF THE CORTICAL

MATERIAL

PROBLEMS IN ENSURING IN-THE-BAG IOL PLACEMENT

ISSUES WITH PROPER ALIGNMENT OF TORIC IOLs


CONSEQUENCES

OF SMALL PUPIL PHACO SURGERY


INTRAOPERATIVE FLOPPY IRIS SYNDROME

(IFIS)

PROGRESSIVE PUPILLARY

CONSTRICTION DURING

SURGERY

A MARKED PROPENSITY FOR

THE IRIS TO PROLAPSE TO THE

PHACO AND SIDEPORT

INCISIONS

FLOPPY IRIS THAT BILLOWS

IN RESPONSE

TO NORMAL IRRIGATING

CURRENTS IN THE AC

J.CAMPBELL, D.CHANG (2004)


Santanella RM, et al. The effect of α1a- adrenergetic receptor antagonist Tamsulosin (Flomax) on the iris dilator muscle anatomy.

Ophthalmology 2010, May

IRIS DILATOR SMOOTH MUSCLE

Control subject Tamsulosin subject

Control (26 eyes) 8.50 ± 1.61 μm

Tamsulosin (25 eyes) 6.53 ± 1.99 μm (p<0.006)

52 cadaveric eyes from 27 male patients

KEY POINTS

FOR THE DECISION MAKING

PUPIL DIAMETER

BIOMECHANICAL PROPERTIES OF THE

IRIS TISSUE


THE STEP-WISE APPROACH IN MANAGING SMALL PUPILS

PHENYLEPHRYNE / EPINEPHRINE

INTRACAMERAL INJECTION

VISCODILATATION

POSTERIOR SYNECHIOLYSIS

PUPIL STRETCHING TECHNIQUE

PUPIL EXPANDER DEVICES


STEP-WISE APPROACH


INTRACAMERAL MYDRIARTICS

LIDOCAINE / EPINEPHRINE MIXTURE (EPI-SUGARCAINE)

Sugar JK. Use of epinephrine for IFIS prophylaxis. JCRS 2006 32(7): 1074-1075

9 cc BSS Plus

3 cc 4% Lidocaine (preservative-free)

4 cc 1:1000 Epinephrine (bisulfite-free)

2.5% PRESERVATIVE-FREE EPINEPHRINE (Minims)

1:1000 (1 mg/ml) EPINEPHRINE

(in glass vial containing bisulfite 0.1%)

diluted x4 times with BSS/BSS Plus


PUPIL EXPANSION DEVICES

METAL HOOKS

PLASTIC HOOKS

IRIS RING (MORCHER)

PERFECT PUPIL (MILVELLA)

GRAETHER EXPANDER

SIEPSER RING

MALYUGIN RING (MST)


IRIS HOOKS


IRIS HOOKS


Significant advantage: possibility to fixate the iris and the capsule to the limbus

IRIS HOOKS


8

IRIS HOOKS

PERIMETER OF THE SQUARE > PERIMETER OF THE CIRCLE


PERFECT PUPIL (Milvella Ltd.) 5S RING (Morcher GmbH)

GRAETHER RING (Eagle Vision Inc.)

CLARKE RING

Main advantages of pupil expander rings: placement through themain incision (multiple additional paracentheses aren’tnecessary); protection of the iris margin; prevention of irissphincter overstretching.

PAPER CLIP IRIS FIXATION MECHANISM


6.25 mm • LESS STRESS TO THE IRIS TISSUE

• EASIER TO IMPLANT AND REMOVE

• BETTER FOR SMALL EYES

5-0 POLYPROPYLENE


5-0 POLYPROPYLENE


7.0 mm • IFIS CASES - PUPIL STARTS OF BIGGER

• CERTAIN PHACO TECHNIQUES - FLIP,

DIVIDE&CONQUER, etc

• IOL DESIGN AND IMPLANTATION METHOD

IRIS FIXATION POINTS

ADVANTAGES

8 FIXATION POINTS

ABSENCE OF SHARP EDGES

MINIMAL TRAUMA TO THE IRIS TISSUE

RELIABLE CLAMPING MECHANISM

FLEXIBILITY

INJECTABILITY

LOW PROFILE


SURGICAL TECHNIQUE


IMPLANTATION PEARLS

OPERATING UNDER TOPICAL –

INJECT LIDOCAINE + PHENYLEPHRINE INTO AC

DO NOT OVERFILL A/C WITH OVD

POSITION INJECTOR TIP CLOSE TO THE IRIS MARGIN

SLOWLY WITHDRAW THE INSERTER WHILE

EXPELLING THE RING


>2.2 mm incision

SURGICAL TECHNIQUE

with


IMPLANTATION PEARLS

IF THE PUPIL IS TOO SMALL:

- TRY TO STRETCH FIRST

- USE BIMANUAL TECHNIQUE WHILE ENGAGING

THE SCROLLS

IF THE PUPIL IS SMALL AND/OR ANTERIOR LENS

SURFACE IS PROLATE:

IT IS HARD TO ENGAGE BOTH LATERAL SCROLLS WHILE

INJECTING - HELP WITH THE SIDEPORT INSTRUMENT (OSHER/

MALYUGIN RING MANIPULATOR, LESTER OR KUGLEN HOOK)

=2.2 mm incision

SURGICAL TECHNIQUE

with


REMOVAL PEARLS

DISENGAGE AT LEAST 2 SCROLLS (DISTAL & PROXMAL)

DISPLACE THE RING A BIT DOWN FROM THE INCISION

USE THE 2ND INSTRUMENT HELP TO POSITION THE

PROXIMAL SCROLL ON THE INJECTOR PLATE

IF HARD TO ACCESS THE PROXIMAL SCROLL UNDER

THE MAIN INCISION – ROTATE THE RING CLOCKWISE

WHILE WITHDRAWING – PRESS ON BOTH LATERAL

SCROLLS AS THEY MERGE TOGETHER

SURGICAL TECHNIQUE

TIP: DISENGAGE DISTAL SCROLL FIRST


1.8 mm incision

SURGICAL TECHNIQUE

with


1.8 mm MICS PEARLS

INSERTER DOES NOT ENTER THE CORNEAL TUNNEL

(WOUND-ASSISTED INJECTION)

IN MOST CASES NOT POSSIBLE TO ENGAGE THE DISTAL AND

LATERAL SCROLLS – LAY THE RING FLAT ON THE IRIS

USE SIDEPORT INSTRUMENT TO POSITION THE SCROLLS

ONE BY ONE (BETTER COUNTERCLOCKWISE)

INSERT OPPOSITE SCROLLS FIRST

WHILE REMOVING – DEPRESS THE INTERNAL LIP OF THE

CORNEAL INCISION TO AVOID CATCHING IT WITH THE RIGHT

LATERAL SCROLL

in FLACS



Incomplete capsulotomy using femtosecond laser with a pupil expansion device

JCRS 2014, Volume 40, Issue 4, P. 513-694

CONCLUSIONS

IN SMALL PUPIL CASES MY RECOMMENDATION IS TO FOLLOW THE

STEPWISE APPROACH

TWO MAIN DRIVERS FOR THE DECISION TO USE PUPIL EXPANDER

DEVICE:

- SIZE OF THE PUPIL

- BIOMECHANICAL PROPERTIES OF THE IRIS

ADDED MANIPULATIONS AND COST OF THE MECHANICAL DEVICE

ARE BY FAR OUTWEIGHTED WITH THE SAFETY ISSUES


surgical strategies for small pupils - malyugin ring

Health & Medicine

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