“Evaluation of Use of Pupil Expansion Device in Resident-Performed Phacoemulsification Surgery”

1. “Evaluation of Use of Pupil Expansion Device in Resident-Performed Phacoemulsification Surgery” Jennifer H. Hung, MDKristiana D. Neff, MD Department of Ophthalmology University of South Carolina, Columbia, SC The authors have no financial interest in the subject matter of this e-poster.

2. Background • Intraoperative floppy iris syndrome (IFIS) is a recognized triad composed of: • 1) billowing of a flaccid iris stroma • 2) progressive intraoperative pupil constriction • 3) 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

3. Purpose • To evaluate the use of the Malyugin pupil expansion device in patients who underwent resident-performed phacoemulsification cataract surgery at one surgical center • To describe intraoperative and postoperative complications encountered during early resident use Correct positioning of all eyelets of Malyugin ring using injector

4. Methods • Retrospective chart review of all patients who underwent phacoemulsification surgery at one surgical center from August 2009 to August 2010 • Inclusion criteria: • 1) resident-performed phacoemulsification • 2) use of Malyugin ring intraoperatively • 3) complete documentation of intraoperative note and postoperative ophthalmic examinations. • Included 43 eyes of 36 male patients

5. Methods • Intraoperative 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.

6. 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

7. Results • Iris 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.

8. Results • Postoperative 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)

9. Discussion of Complications     

10. Discussion • Understanding potential complications of Malyugin ring use is critical for safe usage • Postoperative 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

11. Conclusions • With 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.

12. References 1. 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.