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Sato T. Eight-Chop Technique in Phacoemulsification Using Iris Hooks for Patients with Cataracts and Small Pupils. J Clin Med 2024; 13:7298. [PMID: 39685756 DOI: 10.3390/jcm13237298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Revised: 11/14/2024] [Accepted: 11/28/2024] [Indexed: 12/18/2024] Open
Abstract
Objectives: This study investigated the efficacy and safety of performing phacoemulsification using the eight-chop technique with iris hooks in patients with small pupils. Methods: The iris hooks and control groups each included 65 eyes. Cataract surgeries were performed using the eight-chop technique. The operative time, phaco time, aspiration time, cumulative dissipated energy, and volume of fluid used were measured. Best-corrected visual acuity, corneal endothelial cell density (CECD), and intraocular pressure (IOP) were measured preoperatively and postoperatively. Results: In total, 130 eyes of 107 patients (mean age, 75.9 ± 7.1 years; 58 men, 72 women) with cataracts were evaluated. The mean operative time, phaco time, aspiration time, cumulative dissipated energy, and volume of fluid used were 10.6 min, 20.7 s, 101.1 s, 7.8, and 38.0 mL, respectively, in the iris hooks group and 4.6 min, 16.2 s, 72.1 s, 7.0, and 28.9 mL, respectively, in the control group. The decrease in CECD at 19 weeks postoperatively was 2.1% and 1.2% for the iris hooks and control groups, respectively. In both groups, IOP decreased significantly (all p < 0.01) at 7 and 19 weeks postoperatively. No intraoperative complications were found in either group. Conclusions: The eight-chop technique using iris hooks resulted in a small postoperative reduction in CECD and excellent values for intraoperative outcome measures. In addition, those cataract surgeries were very short, efficient, and safe, without complications. The eight-chop technique using iris hooks could provide an ideal solution for patients with small pupils.
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Affiliation(s)
- Tsuyoshi Sato
- Department of Ophthalmology, Sato Eye Clinic, Nemoto 3-3, Matsudo-shi 271-0077, Chiba-ken, Japan
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Gupta S, Shyamsundar K, Pushkar K, Agrawal M, Mishra A, Tripathi A, Singh M. A randomized control study on post-operative iris distortion following small-pupil cataract surgery using B-HEX pupil expander versus Malyugin ring. Med J Armed Forces India 2024; 80:560-565. [PMID: 39309579 PMCID: PMC11411337 DOI: 10.1016/j.mjafi.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 05/05/2024] [Indexed: 09/25/2024] Open
Abstract
Background The aim of the study was to evaluate postoperative pupil distortion following small pupil cataract surgeries performed using B-HEX and Malyugin rings (MR). Methods A randomized control trial was conducted from June 2020 to June 2023 at a tertiary eye-care hospital. The study consisted of 64 participants for cataract surgery with small pupil. There were two groups, one undergoing surgery with the use of B-HEX pupil expander and other with MR intraoperatively and the rest of the surgery was proceeded as per the convention. Areas of preoperative and postoperative images was calculated, put into an online software and pupil distortion was calculated in percentage. Two-tailed t-test was used to see the difference between the two groups. Results Mean age at presentation was 70.5 ± 10.12 years. Most common cause for small pupil was tamsulosin therapy. Mean size of small-pupil was 3.0 ± 1.1 mm. With the application of two rings, mean pupillary area preoperatively was 4178.23 ± 1589.46 and postoperatively was 6100.44 ± 2658.28 following the use of MR, respectively and 30,002.93 ± 13,193.40 preoperatively and 37,648.26 ± 15,207.01 postoperatively following the use of B-Hex ring respectively. Comparing baseline area from pupillary area at 1-month follow-up, a significant increase was noted for both the rings. Also, MR caused significantly more pupillary distortion compared to B-HEX ring (p < 0.05). Conclusion MR causes significantly more pupillary distortion in the postoperative period compared to B-HEX ring. Though, both the rings cause pupillary distortion, these devices expand the surgical area adequately, ease the procedure, decrease risk of complications achieving good functional visual outcomes.
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Affiliation(s)
- Simple Gupta
- Associate Professor (Ophthalmology), Command Hospital (Northern Command), Udhampur, India
| | | | - Kumar Pushkar
- Associate Professor (Community Medicine), Command Hospital (Southern Command), Pune, India
| | - Mohini Agrawal
- Assistant Professor (Ophthalmology), Military Hospital, Jalandhar Cantt, Punjab, India
| | - Avinash Mishra
- Professor (Ophthalmology), Military Hospital, Jalandhar Cantt, Punjab, India
| | - Abhishek Tripathi
- Resident, Department of Ophthalmology, Armed Forces Medical College, Pune, India
| | - Manish Singh
- Assistant Professor (Respiratory Medicine), Command Hospital (Northern Command), Udhampur, India
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Potti S, Reddy Sodum N. Comparison of pupil expansion devices in small pupil phacoemulsification. Indian J Ophthalmol 2024; 72:S664-S668. [PMID: 38389262 PMCID: PMC11338422 DOI: 10.4103/ijo.ijo_1420_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/11/2023] [Accepted: 12/01/2023] [Indexed: 02/24/2024] Open
Abstract
PURPOSE To study the outcomes of phacoemulsification in small pupils (≤4 mm) using pupil expansion devices at a tertiary eye care center in South India. METHODS The study design is prospective, randomized, comparative, and interventional. Mechanical pupil dilatation with iris retractors (group I), B-HEX ring (group II), and Gupta ring (group III) was compared with respect to pupil size achieved (intraoperative), total surgical time, device addition time, complications, endothelial cell loss, and postoperative best corrected visual acuity. RESULTS Among 36 participants (12 in each group), the mean pupil size, total surgical time, and device addition time were maximum with iris retractors. Intraoperatively, sphincter tear was seen in two eyes in the iris retractors group and one eye in the Gupta ring group. In the B-HEX ring group, only two flanges of the ring could be engaged in two participants, one patient had iris bleeding (during stretching of the iris), and one patient had anterior lens capsular tear. Among all three groups, there was no statistically significant difference in best corrected visual acuity (BCVA), endothelial cell count, and coefficient of variation obtained in the preoperative period, postoperative Day 7 and Day 30, respectively. CONCLUSION In our study, in more than 50% of cases, the cause of small pupil was idiopathic/senile. Among nonidiopathic causes, PXF was the most common association. Although iris retractors are cost-effective and give maximum intraoperative dilatation, there is a need of four additional side ports to be made, thus increasing the total surgical time and device addition time. On the other hand, B-HEX and Gupta ring provide comparable intraoperative dilation and device addition time and also have comparable postoperative outcomes in terms of postoperative pupil size and complications.
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Affiliation(s)
- Sudhakar Potti
- Sankara Eye Hospital, Pedakakani, Guntur, Andhra Pradesh, India
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Ganesh S, Brar S, Chakma A. A new intraocular lens marker to guide the implantation of toric intraocular lenses in small and mid-dilating pupils. Indian J Ophthalmol 2023; 71:2251-2253. [PMID: 37202962 PMCID: PMC10391429 DOI: 10.4103/ijo.ijo_1979_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Insufficient pupillary dilatation is a significant challenge during cataract surgery, as it increases the risk of various intraoperative complications. Implantation of toric intraocular lenses (TIOL) is particularly difficult in eyes with small pupils, as the toric marks are provided in the periphery of the IOL optic, making the visualization of the same difficult for proper alignment. Attempts at visualizing these marks using a second instrument such as a dialler or iris retractor lead to additional manipulations in the anterior chamber resulting in increased chances of postoperative inflammation and intraocular pressure rise. A new intraocular lens (IOL) marker to guide the implantation of TIOLs in eyes with small pupils is described, which can potentially be beneficial in achieving accurate alignment of toric IOLs in small pupils, without the need for additional manipulations, thus improving safety, efficacy, and success rates of TIOL implantation in these eyes.
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Affiliation(s)
- Sri Ganesh
- Department of Phaco and Refractive, Nethradhama Superspeciality Eye Hospital, Bangalore, India
| | - Sheetal Brar
- Department of Phaco and Refractive, Nethradhama Superspeciality Eye Hospital, Bangalore, India
| | - Anwesha Chakma
- Department of Phaco and Refractive, Nethradhama Superspeciality Eye Hospital, Bangalore, India
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Kęcik D, Grabska-Liberek I, Jurowski P, Mrukwa-Kominek E, Omulecki W, Romanowska-Dixon B, Szaflik JP, Romaniuk W, Szaflik J, Kopacz D, Mianowska K. Pupil diameter during cataract surgery after intracameral injection of the first ready-to-use combination of mydriatics and anaesthetic at the beginning of surgery in patients with a preoperative pupil diameter <6 mm. Acta Ophthalmol 2023; 101:e81-e87. [PMID: 35974455 PMCID: PMC10087216 DOI: 10.1111/aos.15218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 06/07/2022] [Accepted: 07/19/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE We evaluated, in a real-life setting, the effect of Mydrane® (ready-to-use combination of tropicamide, phenylephrine hydrochloride and lidocaine, injected into the anterior chamber at the beginning of cataract surgery to induce mydriasis and intraocular anaesthesia) on the pupil diameter during cataract surgery in patients with a preoperative pupil diameter <6 mm after the use of topical mydriatics. METHODS We collected and analysed the data of 59 consecutive patients whose pupils dilated to a diameter <6 mm after the administration of mydriatic eye drops during the preoperative visit and who received Mydrane® during cataract surgery. RESULTS In the group of 59 patients with a preoperative pupil diameter <6 mm after topical mydriatics, cataract surgery was performed in 36 patients (61.0%) using only Mydrane® to obtain mydriasis, with no additional drug or medical device. The mean pupil diameters in this group (36 of 59) during the preoperative assessment after topical mydriatics and just before capsulorhexis when Mydrane® was injected during surgery were 5.1 ± 0.74 and 6.15 ± 1.14 mm. Additional drugs were used in 23 patients (39%). In this group, the mean pupil diameters after topical mydriatics and just before capsulorhexis using Mydrane® were 4.58 ± 1.06 and 5.6 ± 1.26 mm, respectively. CONCLUSION In a real-life setting, the mean pupil diameter achieved during cataract surgery after the intracameral injection of Mydrane® in patients with a preoperative pupil diameter <6 mm was over 1 mm larger than the mean pupil diameter after topical mydriatics, despite the trauma caused by the operation.
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Affiliation(s)
- Dariusz Kęcik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Grabska-Liberek
- Department of Ophthalmology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Piotr Jurowski
- Department of Eye Diseases, Medical University of Lodz, Lodz, Poland
| | - Ewa Mrukwa-Kominek
- Department of Ophthalmology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Wojciech Omulecki
- Department of Ophthalmology, Medical University of Lodz, University Hospital No 1, Lodz, Poland
| | - Bożena Romanowska-Dixon
- Department of Ophthalmology and Ocular Oncology, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek P Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Wanda Romaniuk
- Department of Ophthalmology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Jerzy Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Kopacz
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
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Sepulveda-Beltran PA, Levine H, Gibbons AG, Maharaj A, Choi DS, Martinez JD, Correa ZM, Amescua G, Harbour JW. Post-Radiation Cataract Management: Outcomes in Individuals with Uveal Melanoma. CURRENT OPHTHALMOLOGY REPORTS 2022. [DOI: 10.1007/s40135-022-00304-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wang JD, Zhang JS, Li M, Mao YY, Mayinuer Y, Wan XH. Comparison of different pupil dilatation methods for phacoemulsification in eyes with a small pupil. BMC Ophthalmol 2022; 22:173. [PMID: 35436870 PMCID: PMC9016963 DOI: 10.1186/s12886-022-02402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To compare 6 methods for intraoperative pupil dilatation in eyes with insufficient pupil size during phacoemulsification. METHODS This was a prospective case-control study. 99 microcoria cataract patients (120 eyes) were collected and were divided into 6 groups(20 eyes each group), and their pupils were dilated by bimanual stretching pupil (group I), pupil radial cut open(group II), mechanical pupil dilatation with iris-retractor hooks (group III), OASIS iris expander (group IV), and Malyguin-ring (Microsurgical company, America) (group V), B-HEX Pupil Expander (Med Invent Devics, India)(group VI),respectively. 3.0 mm clear corneal incision were used in phacoemulsification. All cases were followed up at 1 week and 1, 3, 6 months after the surgery. The best corrected visual acuity (BCVA), intraocular pressure(IOP), corneal endothelium cell density(ECD), pupil diameter(PD) of before and after surgery were compared. RESULTS One same doctor finished all cataract surgeries successfully. The eyes' condition before surgery and at 6 months after surgery were compared. There were no significant statistical differences for the conditions of the eyes before surgery among six groups. The ECDs were better at 6 months postoperatively in group III and V, median values: 2114/mm2, 1961/mm2. PD was largest in group II (median value: 5.5 mm), which was significantly larger than other groups (Padjusted < 0.05). CONCLUSIONS All 6 methods used in this study were effective for the mechanical dilatation of small pupils and didn't affect the postoperative visual acuity and intraocular pressure in microcoria cataract phacoemulsification. Iris-retractor hooks and the Malyugin Ring can reduce intraoperative corneal endothelium cell loss. Postoperative PD is larger when the iris was cut open radially.
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Affiliation(s)
- Jin Da Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital of Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, 100005, China
| | - Jing Shang Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital of Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, 100005, China
| | - Meng Li
- Beijing Tongren Eye Center, Beijing Tongren Hospital of Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, 100005, China
| | - Ying Yan Mao
- Beijing Tongren Eye Center, Beijing Tongren Hospital of Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, 100005, China
| | - Yusufu Mayinuer
- Beijing Tongren Eye Center, Beijing Tongren Hospital of Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, 100005, China
| | - Xiu Hua Wan
- Beijing Tongren Eye Center, Beijing Tongren Hospital of Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, 100005, China.
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Intraoperative floppy iris syndrome: an updated review of literature. Int Ophthalmol 2021; 41:3539-3546. [PMID: 34184151 DOI: 10.1007/s10792-021-01936-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
Intraoperative Floppy iris syndrome(IFIS) remains a challenge for surgeons during phacoemulsification. Initially, it was related to the use of tamsulosin, an alpha adrenergic receptor blocker used in benign prostatic hyperplasia. Subsequently, other alpha adrenergic receptor such as alfuzosin, terazosin and doxazosin alongwith different other class of medications and systemic risk factors were identified. Other class of medications includes 5-alpha reductase inhibitor, angiotensin receptor antagonist, benzodiazepines, antipsychotics and antidepressants. Other risk factors include increasing age, male gender, diabetes, hypertension and decreased preoperative pupil diameter. It is very important for surgeons to identify these risk factors preoperatively and take appropriate preoperative and intraoperative measures to tackle the dreaded complications of IFIS. Sometimes, it is important for an ophthalmologist to work in cooperation with physician and urologist to minimize the complications. In conclusion, awareness of the risk factors associated with IFIS, their detailed preoperative assessment and intraoperative measures and surgical intervention is crucial in addressing IFIS. Lack of awareness can turn a routine, uneventful surgery into one with significant visual morbidity.
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Williams ER, Patnaik JL, Miller DC, Lynch AM, Davidson RS, Kahook MY, Seibold LK. Iris manipulation during phacoemulsification: intraoperative and postoperative complications. Int J Ophthalmol 2021; 14:676-683. [PMID: 34012881 DOI: 10.18240/ijo.2021.05.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/19/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To quantify intraoperative and postoperative complications in complex phacoemulsification cataract extraction (phacoemulsification) with iris manipulation compared to non-complex and complex phacoemulsification without iris manipulation. METHODS All phacoemulsification cases at the University of Colorado between January 1, 2014, and June 30, 2017 were included. Exclusion criteria for the primary outcome of intraoperative complications were planned combination surgery and eyes with less than 28d follow-up. Exclusion criteria for the secondary outcomes of postoperative complications were unplanned additional surgery, and chronic steroid eye drop use prior to surgery. Data including sex, race/ethnicity, surgery length, visual acuity, intraoperative and postoperative complications, and intraocular pressures (IOP) were collected and analyzed utilizing general linear and Logistic regression modeling. RESULTS The medical records of 5772 eyes were reviewed (500 complex without iris manipulation, 367 with iris manipulation). The number of any intraoperative complication in the complex with iris manipulation and complex without iris manipulation groups was 15 (4.1%) and 26 (5.2%), respectively, compared to 41 (0.8%) in the non-complex group. Postoperative inflammation was found in 135 (2.8%) non-complex cases, 20 (4.1%) complex cases without iris manipulation, and 20 (5.6%) complex cases with iris manipulation. The adjusted odds ratio of postoperative inflammation in phacoemulsification with iris manipulation compared to non-complex was 2.3 (95%CI: 1.3-4.0, P=0.005). The rate of IOP spikes >10 mm Hg was significantly greater in cases with iris manipulation (P=0.001). CONCLUSION Complex cases have more intraoperative complications. However, only complex cases with iris manipulation led to increase rates of postoperative inflammation and IOP spikes >10 mm Hg.
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Affiliation(s)
- Eric R Williams
- Department of Ophthalmology, Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Jennifer L Patnaik
- Department of Ophthalmology, Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - D Claire Miller
- Department of Ophthalmology, Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Anne M Lynch
- Department of Ophthalmology, Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Richard S Davidson
- Department of Ophthalmology, Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Malik Y Kahook
- Department of Ophthalmology, Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Leonard K Seibold
- Department of Ophthalmology, Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Yang K, Song C, Li J, Zhang W, Liu Z, Zhao Y. Application of a prechop technique using a reverse chopper in small pupil cataract surgery. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1189. [PMID: 33241038 PMCID: PMC7576071 DOI: 10.21037/atm-20-5241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To analyze the value of a prechop technique for splitting the nucleus of the lens using a reverse chopper in small-pupil cataract surgeries. A prospective case-control study. Thirty-four cataract patients (34 eyes) who were treated in our center from March 2019 to December 2019 were enrolled and then divided into two groups: small pupil group (18 patients; 18 eyes) and normal pupil group (16 patients; 16 eyes). Methods The prechop technique was applied in both groups, and the patients were followed up for three months. The best-corrected visual acuity (BVCA), surgical complications, corneal endothelial cell loss, pupil function, operative time, and cumulative dissipated energy (CDE) were compared between these two groups, and the safety of the nucleus-chopping technique was evaluated. Data were analyzed using the SPSS 23.0 software packages. BVCA, surgical complications, rate of corneal endothelial cell loss, pupil function, operative time, and CDE. Results The surgery was smooth in all cases. The operative time, intraoperative ultrasound energy consumption, BVCA, and surgical complications indicated no significant difference between the two groups (all P>0.05). In the small pupil group, BVCA was significantly improved after surgery and achieved its optimal value three months after surgery (χ2=49.38; P=0). The diameter of the pupil was about 3.22 mm in the small pupil group before nucleus chopping. The postoperative pupil morphology was not statistically different from that before surgery (pupil morphology: χ2=0.131; P=0.717); however, the pupillary light reflex was significantly improved after surgery (χ2=8.378; P=0.004), and the pupil diameter was significantly increased (T=-3.494; P=0.003). The rate of corneal endothelial cell loss was higher in small pupil group than in the normal pupil group in the 3rd postoperative month, but the difference was not statistically significant (T=-0.023; P=0.982). Conclusions The prechop technique using a reverse chopper in small-pupil cataract surgery occupies a similar operative time, cumulative energy consumption during operation, BVCA, pupil morphology, and rate of corneal endothelial cell loss, comparing with those in normal-pupil cataract surgery. To such a degree, it is a safe, high-efficiency, a simple and easy-to-operate nucleus-chopping technique that can be used in small-pupil cataract surgery.
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Affiliation(s)
- Ke Yang
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chenjie Song
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jiaxin Li
- Medical School, Pingdingshan University, Pingdingshan, China
| | | | | | - Yang Zhao
- Beijing Tongren Eye Center, Beijing Key Laboratory of Ophthalmology and Visual Science, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Predicting zonular strength based on maximum pupillary mydriasis in patients with pseudoexfoliation syndrome. Med Hypotheses 2020; 146:110402. [PMID: 33279326 DOI: 10.1016/j.mehy.2020.110402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/12/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
Pseudoexfoliation Syndrome (PXFS) is considered a systemic disorder with significant ocular manifestations ranging from corneal decompensation, non-dilating pupil, zonular weakness, subluxated lens, and glaucoma. PXFS may lead to increased complications during routine cataract surgery. Zonular dialysis is a common complication during or after cataract surgery in such patients. However, not all patients with pseudoexfoliation are at a higher risk. We hypothesize that there is an inverse correlation between the maximum pupillary dilation and the degree of zonular disintegration. Available evidence supporting the hypothesis is discussed. We propose a new clinical classification for predicting the zonular strength based on the maximum pupillary dilation so that it can serve as a guide to identify PXFS patients who are at high risk of complications during or after cataract surgery.
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Abstract
PURPOSE OF REVIEW Cataract surgery is the most common surgical procedure performed worldwide. Small pupils have been an eternal challenge for cataract surgeons; insufficient pupil dilation is associated with increased complication rates, including capsule rupture, vitreous loss, iris trauma or postoperative inflammation. The aim of the current review is to present the methods for pupil dilation and the risk factors for a small pupil in a cataract patient. RECENT FINDINGS Risk factors for intraoperative small pupil include diabetes, intraoperative floppy iris syndrome, pseudoexfoliation syndrome, receiving glaucoma medications, having undergone previous ocular surgery and iris sphincter sclerosis from aging. There is a wide range of options to manage the small pupil, including pharmacological treatment, mechanical stretching, dilation with iris hooks or pupil expanders. We recommend a stepwise approach for intraoperative pupil dilation, from pharmacological mydriasis to pupil expanders. SUMMARY The current article discusses risk factors for a small pupil and the methods for pupil dilation in a cataract patient. Every cataract surgeon needs to be ready to cope with a small pupil, both manifesting preoperatively and intraoperatively.
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de Faria A, Giorgi R, Cohen Salmon M, Bonnel S, Holweck G, Le Corre A, Chazalon E. [Same-eye comparison of pupillary dilation with an intraoperative standardized intracameral combination of mydriatics (Mydrane®) versus a preoperative ophthalmic (Mydriasert®) in standard cataract surgery in non-diabetic patients (French translation of the article)]. J Fr Ophtalmol 2019; 42:1068-1077. [PMID: 31668379 DOI: 10.1016/j.jfo.2019.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/26/2018] [Accepted: 02/04/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Cataract surgery is the most commonly performed surgery in the world, and its success depends in part on the quality of mydriasis. PURPOSE To compare, for the same eye, the pupillary dilation obtained with Mydrane® (standardized intracameral solution of 0.02% tropicamide, combined with 0.31% phenylephrine and 1% lidocaine) intraoperatively versus Mydriasert® (0.28mg tropicamide insert and 5.4mg phenylephrine) with a contact time between 45 and 60 minutes in the preoperative period. METHODS Single center prospective study from November 2016 to January 2018 at the Laveran Army Instructional Hospital in Marseille. Patients referred for surgery were dilated at the preoperative consultation with Mydriasert®. The pupillary diameter after 45-60 minutes of contact with the insert was manually measured, by two different examiners, through the "iris image" tab of the Pentacam® elevation topography. Patients were dilated on the day of their cataract surgery with 0.2cc of Mydrane® injected in the anterior chamber through a paracentesis. Thirty seconds later, prior to injection of viscoelastic, an eye photograph was taken by screen capture. The pupillary diameter was evaluated by two different examiners with to the Piximeter 5.9 metrology software. The difference in pupil dilation between Mydriasert® and Mydrane® was tested with the paired series Student t-test. RESULTS In total, 111 eyes of 82 patients were included. Mydriasert® achieved a mean pupillary dilation of 7.21±0.79mm. The mydriasis obtained with Mydrane® averaged 6.35±0.8mm. This difference of 0.86mm was statistically significant (P<0.001) with a confidence interval of 95% [-0.97; -0.74]. CONCLUSION On average, Mydrane® dilates the pupil less than Mydriasert®. However, the mydriasis obtained with Mydrane® remains comfortable for the performance of the capsulorhexis. It helps save preoperative time and affords additional anesthetic to the cataract surgery. Nevertheless, the use of Mydriasert® is beneficial when extra mydriasis is required.
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Affiliation(s)
- A de Faria
- Ophthalmology, HIA Laveran, Marseille, France.
| | - R Giorgi
- Department of Public Health (BIOSTIC), hôpital la Timone, APHM, Marseille, France
| | | | - S Bonnel
- Ophthalmology, HIA Laveran, Marseille, France
| | - G Holweck
- Ophthalmology, HIA Laveran, Marseille, France
| | - A Le Corre
- Ophthalmology, HIA Laveran, Marseille, France
| | - E Chazalon
- Ophthalmology, HIA Laveran, Marseille, France
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Lu K, Garcia M, Tian J, Karanjia R. Series of cataract surgeries with I-ring pupil expansion ring. World J Ophthalmol 2019; 8:1-6. [DOI: 10.5318/wjo.v8.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/28/2019] [Accepted: 10/04/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The retrospective review of I-ring pupil expansion ring use is designed to examine the patient characteristics and associated surgical challenges in a clinical practice. The hypothesis is that I-ring provides a necessary additive tool in dealing with challenging cataract surgeries with small pupils.
AIM To document the safety profile and use of I-ring pupil expansion ring in a clinical practice.
METHODS A retrospective chart review of 12 consecutive cases within the same year (2016) of cataract surgeries employing I-ring pupil expansion ring (Beaver-Visitec, International) by a single surgeon at the same ambulatory surgical center was conducted. Demographic, pre-op, intra-op, and post-op data were recorded. Total number of cataract cases performed was also recorded.
RESULTS 8 of 12 cases were planned I-ring cases. 1 case was decided intraoperatively when femtosecond laser caused the pupil to shrink. The other 3 cases were also decided upon intraoperatively when pupil was deemed to be small. 7 patients had IFIS from Flomax use. 2 patients had pseudoexfoliation syndrome as the cause of small pupil. 2 patients had narrow angles with brunescent cataracts. 2 patients had pre-op partial zonular dehiscence. 1 patient had 360o of posterior synechiae. 2 cases had ruptured posterior capsule that required anterior vitrectomy. No complications were attributed to the pupil expansion ring. A total of 296 cataract surgeries were performed that year by the surgeon, making the rate of pupil ring use 4.1%.
CONCLUSION Small pupil requiring pupil expansion ring during cataract surgery is often associated with other challenges, such as brunescent cataract, zonular weakness, and posterior synechiae in this series. I-ring helped to reduce at least one challenge in these difficult cases.
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Affiliation(s)
- Kenneth Lu
- Doheny Eye Institute, University of California, Los Angeles, CA 91007, United States
| | - Martin Garcia
- Doheny Eye Institute, University of California, Los Angeles, CA 91007, United States
| | - Jack Tian
- Doheny Eye Institute, University of California, Los Angeles, CA 91007, United States
| | - Rustum Karanjia
- Doheny Eye Institute, University of California, Los Angeles, CA 91007, United States
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Same-eye comparison of pupillary dilation with an intraoperative standardized intracameral combination of mydriatics (Mydrane®) versus a preoperative ophthalmic (Mydriasert®) in standard cataract surgery in non-diabetic patients. J Fr Ophtalmol 2019; 42:e339-e348. [DOI: 10.1016/j.jfo.2019.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/24/2019] [Accepted: 06/16/2019] [Indexed: 11/21/2022]
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Borkenstein AF, Borkenstein EM. Surgical experience with a redesigned, fully preloaded, hydrophobic acrylic intraocular lens in challenging cases of pseudoexfoliation syndrome, phacodonesis, and small pupils. Clin Ophthalmol 2019; 13:199-206. [PMID: 30774299 PMCID: PMC6348969 DOI: 10.2147/opth.s194420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Purpose The purpose of this study was to describe our surgical experience and evaluate safety and postoperative outcomes of a fully preloaded, monofocal, hydrophobic acrylic intraocular lens (IOL) (CT LUCIA 611P) with a newly designed optic-haptic junction in severe cases of pseudoexfoliation (PXF) syndrome, phacodonesis, and small pupils. Setting This study was conducted in Borkenstein & Borkenstein, private practice, Privatklinik der Kreuzschwestern Graz, Austria. Patients and methods This study presents outcomes of 15 eyes of 15 patients implanted with CT LUCIA 611P IOL with improved optical properties and more rigid and wider optic– haptic junction. All patients had advanced cataract and PXF syndrome, of which phacodonesis was detected in 12 cases and five cases had PXF glaucoma. All eyes had small pupils with no response to mydriatic drops, and the surgery was performed with the use of Malyugin ring. All eyes were targeted for a slight postoperative myopia (−0.25 to −0.50 D). Refractive outcomes were presented for 3 months follow-up, while adverse events were followed up for to 10 months. Results The mean age of the study group was 78.3 years (from 68 to 86 years). Three months postoperatively, the mean manifest spherical equivalent was −0.35 D (from 0.00 to −1.00 D) and all eyes were within ±0.50 D of their preoperative target. No significant refractive shift or refractive surprise occurred during the follow-up of 10 months. Corrected distance visual acuity (CDVA) improved from the mean value of 20/50 preoperatively to 20/20 postoperatively. No intraoperative adverse events were noted. Postoperatively, six eyes presented with a slight decentration or tilt, which did not significantly affect postoperative refraction, CDVA, or patients’ subjective visual symptoms. Conclusion The IOL provided good surgical performance, excellent refractive stability, and predictable outcomes in patients with PXF syndrome. Further studies are necessary to evaluate long-term stability.
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Nderitu P, Ursell P. Iris hooks versus a pupil expansion ring: Operating times, complications, and visual acuity outcomes in small pupil cases. J Cataract Refract Surg 2018; 45:167-173. [PMID: 30527439 DOI: 10.1016/j.jcrs.2018.08.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/06/2018] [Accepted: 08/19/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE To compare iris hooks and a pupil expansion ring (Malyugin ring) in eyes with a small pupil. SETTING Epsom and St. Helier University National Health Service Trust, London, United Kingdom. DESIGN Retrospective case series. METHODS Patients who had primary phacoemulsification cataract surgery from January 1, 2012, to December 30, 2016, were included. Combined procedures and surgeons with fewer than 50 cases were excluded. Anonymized data were demographics, surgeon grade, case complexity, iris hooks or Malyugin ring use, posterior capsule rupture, zonular fiber rupture or dialysis, vitreous loss, operating time, postoperative complications, and visual acuity. RESULTS Of the 9552 cases included, 425 (4.4%) had a small pupil, 314 of which required a pupil expansion ring and 95 iris hooks. Compared with no pupil expander, iris hooks were associated with an additional operating time of 14 minutes for consultants and 24 minutes for trainees. The pupil expansion ring was associated with an additional operating time of 4 minutes and 6 minutes, respectively. Neither pupil expander was associated with more intraoperative complications. The pupil expansion ring was associated with higher postoperative anterior uveitis and corneal edema rates. Pupil expander cases achieved equivalent visual acuity gains. CONCLUSIONS The pupil expansion ring and iris hooks were safe and effective in minimizing intraoperative complications in eyes with a small pupil. The pupil expansion ring was faster to use than iris hooks. Monitoring for signs of postoperative anterior uveitis or cornea edema with careful insertion or removal of pupil expansion rings is advocated.
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Affiliation(s)
- Paul Nderitu
- Epsom and St. Helier University National Health Service Trust, London, United Kingdom.
| | - Paul Ursell
- Epsom and St. Helier University National Health Service Trust, London, United Kingdom
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