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Biaxial phacoemulsification
LETTERS
the help of an iris hook, and there was some iris pigment loss from excess suction toward the tip. After reading the article, I reviewed the chart of the patient and found that he had been on Cardura, a vasopressor, during the past 3 years for the treatment of hypertension. This a-1 receptor antagonist is used widely in the Middle East for the treatment of hypertension. I think the same care should be directed to this medication, especially in the Middle East. Patients should be asked about this medication preoperatively to anticipate and manage the situation properly intraoperatively should the syndrome occur. ALI M. EL-GHATIT, MD Alexandria, Egypt REFERENCE 1. Chang FD, Campbell RJ. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31:664–673
Case 3 is a prominent cataract surgeon who self-referred for cataract consultation and had been using Flomax every day for the previous 5 years. His examination revealed mild cataracts and nonproliferate diabetic retinopathy that had been treated with focal photocoagulation. The most remarkable finding was that his pupils dilated from 4 mm to 8 mm after a single drop of mydriacyl 0.5% and neosynephrine 2.5%. We were befuddled by his immunity to Flomax despite chronic usage. Case 4 is a 70-year-old patient with Parkinson’s disease who had classic and dramatic IFIS during cataract surgery in each eye. His daughter was a nurse practitioner and not only did she state that her father had never used Flomax or any other urologic drug, but she also confirmed this history with his physician. Iris dystonia is probably a result of a constellation of causes, 1 of which is Flomax. Yet even this relationship appears to be complex and confusing at the present time. Both sexes can have IFIS, the susceptibility and severity are highly variable, and there are undoubtedly other medications that may lead to the classic signs in surgery. Perhaps our collaborative efforts will lead to a better understanding of this challenging condition.
Association between IFIS and Flomax We are indebted to Chang and Campbell1 for describing the association between Flomax and intraoperative floppy-iris syndrome (IFIS). Yet, there are many gaps in our understanding that will need to be filled in before the Flomax (tamsulosin) relationship becomes clear. It has been postulated that this a-1A receptor blocker causes damage to the iris, resulting in a loss of tone that in turn is responsible for iris billowing, a prolapsing tendency during surgery, and suboptimal dilation with progressive constriction. The following 4 cases illustrate some of the vagaries and mysteries that remain to be solved. Case 1 is a 70-year-old woman who had phacoemulsification for a routine nuclear cataract. As soon as a clear corneal incision was made, the iris immediately prolapsed into the incision despite a well-constructed tunnel in the presence of sodium hyaluronate 2.3% (Healon5). The iris was gently reposited after removing some of the ophthalmic viscosurgical device (OVD) through the side incision. However, throughout low-infusion emulsification, the iris was billowing like a parachute in a breeze. After the cortex was removed and the intraocular lens was implanted, the shimmering of the iris was dramatic during the removal of Healon5. Reluctantly, the surgeon inquired whether the patient had ever used Flomax. Despite the fact that she was a woman and the initial report found that all 27 patients were men, her response was ‘‘yes,’’ as she recalled using Flomax for urinary hesitancy several years earlier. As a result of this interchange, the clinical staff at the Cincinnati Eye Institute was instructed to ask every patient about previous Flomax use regardless of sex. Case 2 is a 75-year-old patient who was referred for routine cataract surgery. He had a history of benign prostatic hypertrophy and kept a detailed medical record that indicated that he had used Flomax 3 years earlier for only 1 week before discontinuing the drug. No other a-blocker was substituted, which was confirmed by his urologist. In the operating room, his pupils failed to dilate beyond 4.0 mm and the iris behavior was consistent with IFIS. The surgeon encountered exactly the same behavior during cataract surgery in the fellow eye 2 months later. This case illustrates that, in some patients, only a short period of time is required for Flomax to cause iris changes leading to IFIS. Moreover, the loss of iris tone does not seem to recover despite a period of years off the medication.
ROBERT H. OSHER, MD Cincinnati, Ohio, USA REFERENCE 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31:664–673
Biaxial phacoemulsification I agree with Arshinoff’s1 comments that the terms bimanual phacoemulsification and microincision phacoemulsification (also known as MICS) do not appropriately describe noncoaxial phacoemulsification. As Arshinoff stated, even with coaxial phacoemulsification, as most of us have been operating for many years with both hands, the standard coaxial procedure has been bimanual. As the new technique of unsleeved phacoemulsification has been introduced over the past few years, it has been referred to by various names by various surgeons, including cold phacoemulsification (which it actually is not). The new unsleeved phacoemulsification procedure has also allowed (actually required) phacoemulsification through a smaller incision. It appears our goal is to try to agree on 1 term for the new procedure. If our goal is to emphasize the unsleeving and if phacoemulsification and aspiration are considered 1 axis and the now-separated irrigation a second axis, then biaxial (as proposed by Arshinoff) would be an appropriate term for the procedure. If, however, we want to emphasize the smaller incision (1.5 mm as opposed to 2.8 mm), then the new procedure could appropriately be called microincision phacoemulsification (or MICSdmicroincision cataract surgery, as proposed by Alio´). When discussing incision length, I have always distinguished the various lengths by the following terms: long incision for extracapsular cataract extraction/intracapsular cataract extraction (10 mm incision), small incision for phacoemulsification with a poly(methyl methacrylate) intraocular lens (IOL) (6 mm incision), miniincision for phacoemulsification with a foldable IOL (3 mm incision), and microincision for phacoemulsification with a foldable IOL (1.5 mm or less incision).
J CATARACT REFRACT SURG - VOL 32, APRIL 2006
547
LETTERS
As the procedure is still in evolution, some cases are performed using unsleeved phacoemulsification through 2 1.5 mm incisions with IOL implantation through an enlarged (or separate) 2.8 mm incision. In this case, one could describe the procedure as biaxial phacoemulsification or microincision phacoemulsification but could not truly call the whole procedure microincision, as only the phacoemulsification portion was performed through a microincision. Only when both phacoemulsification and IOL implantation are performed through 1.5 mm incisions can we truly call the entire procedure microincision. Even this is questionable, as previously pointed out by Osher. If 2 1.5 mm incisions (totaling 3.0 mm of incision length) are used, is it really microincision surgery? If one incision is enlarged to 2.8 mm and the other is left at 1.5 mm (totaling 4.3 mm), is it miniincision surgery? Worse yet, what would a small-pupil biaxial microincision phacoemulsification case (such as in a patient on tamsulosin) that has 2 1.5 mm incisions, 4 0.5 mm incisions for iris hooks, and 1 separate 2.8 mm incision for IOL implantation (7 incisions totaling 7.8 mm) be called? To further confuse the terminology issue, Akahoshi is now performing 1.7 mm (microincision) sleeved coaxial phacoemulsification with IOL implantation through a 1.8 mm incisiondis this coaxial microincision surgery? It would seem appropriate to describe our procedures using both the phacoemulsification technique (coaxial or biaxial) and the incision size (as determined by the IOL technique), such as coaxial miniincision or biaxial microincision. Obviously, we are having fun and enjoying our new and exciting technology and terminology. Only time will tell if these newer smaller-incision, coolertip technique changes will persist as true benefits to our patients.
Figure 2. Elevating the plunger handle before screwing it corrects it position.
HARRY B. GRABOW, MD Sarasota, Florida, USA Figure 3. The tip of the plunger exerts central rather than tangential force.
REFERENCE 1. Arshinoff SA. Biaxial phacoemulsification [letter]. J Cataract Refract Surg 2005; 31:646–647
Silicone lens fracture using IOL injector The case report by Chuah and Rajesh1 describes an intraoperative fracture of an AMO Clariflex silicone posterior chamber lens using the Allergan intraocular lens injector. While we agree that this was the first reported case in the literature, we certainly encountered similar cases in the past while using the Allergan UNFOLDER
injector Silver Series (model PSHST) with the AMO ClariflexC silicone lens. In our experience, the main reason for the fracture was the shearing force of the injector overriding the lens while screwing the plunger (Figure 1). We found that elevating the plunger compensates for any looseness in the injector handle and depresses the tip into the lens, preventing overriding (Figures 2 and 3). This single change in technique allowed us to avoid this problem in our last 500 cases. We agree with the authors that a small tear in the lens usually causes no problems. BASHAR R. MOHAMMED, MB, CHB STEVE R. PERRY, FRCOPHTH Worcester, United Kingdom REFERENCE 1. Chuah JL, Rajesh CV. Intraoperative fracture of AMO Clariflex silicone posterior chamber IOL [correspondence]. J Cataract Refract Surg 2005; 31:1260–1261
Intraoperative retinoscopy Figure 1. Lens fracture results when the plunger overrides the lens.
548
Ianchulev et al.1 describe the use of intraoperative retinoscopic autorefraction to obtain an estimate of intraocular lens (IOL) power needed at the time of cataract extraction.
J CATARACT REFRACT SURG - VOL 32, APRIL 2006
the help of an iris hook, and there was some iris pigment loss from excess suction toward the tip. After reading the article, I reviewed the chart of the patient and found that he had been on Cardura, a vasopressor, during the past 3 years for the treatment of hypertension. This a-1 receptor antagonist is used widely in the Middle East for the treatment of hypertension. I think the same care should be directed to this medication, especially in the Middle East. Patients should be asked about this medication preoperatively to anticipate and manage the situation properly intraoperatively should the syndrome occur. ALI M. EL-GHATIT, MD Alexandria, Egypt REFERENCE 1. Chang FD, Campbell RJ. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31:664–673
Case 3 is a prominent cataract surgeon who self-referred for cataract consultation and had been using Flomax every day for the previous 5 years. His examination revealed mild cataracts and nonproliferate diabetic retinopathy that had been treated with focal photocoagulation. The most remarkable finding was that his pupils dilated from 4 mm to 8 mm after a single drop of mydriacyl 0.5% and neosynephrine 2.5%. We were befuddled by his immunity to Flomax despite chronic usage. Case 4 is a 70-year-old patient with Parkinson’s disease who had classic and dramatic IFIS during cataract surgery in each eye. His daughter was a nurse practitioner and not only did she state that her father had never used Flomax or any other urologic drug, but she also confirmed this history with his physician. Iris dystonia is probably a result of a constellation of causes, 1 of which is Flomax. Yet even this relationship appears to be complex and confusing at the present time. Both sexes can have IFIS, the susceptibility and severity are highly variable, and there are undoubtedly other medications that may lead to the classic signs in surgery. Perhaps our collaborative efforts will lead to a better understanding of this challenging condition.
Association between IFIS and Flomax We are indebted to Chang and Campbell1 for describing the association between Flomax and intraoperative floppy-iris syndrome (IFIS). Yet, there are many gaps in our understanding that will need to be filled in before the Flomax (tamsulosin) relationship becomes clear. It has been postulated that this a-1A receptor blocker causes damage to the iris, resulting in a loss of tone that in turn is responsible for iris billowing, a prolapsing tendency during surgery, and suboptimal dilation with progressive constriction. The following 4 cases illustrate some of the vagaries and mysteries that remain to be solved. Case 1 is a 70-year-old woman who had phacoemulsification for a routine nuclear cataract. As soon as a clear corneal incision was made, the iris immediately prolapsed into the incision despite a well-constructed tunnel in the presence of sodium hyaluronate 2.3% (Healon5). The iris was gently reposited after removing some of the ophthalmic viscosurgical device (OVD) through the side incision. However, throughout low-infusion emulsification, the iris was billowing like a parachute in a breeze. After the cortex was removed and the intraocular lens was implanted, the shimmering of the iris was dramatic during the removal of Healon5. Reluctantly, the surgeon inquired whether the patient had ever used Flomax. Despite the fact that she was a woman and the initial report found that all 27 patients were men, her response was ‘‘yes,’’ as she recalled using Flomax for urinary hesitancy several years earlier. As a result of this interchange, the clinical staff at the Cincinnati Eye Institute was instructed to ask every patient about previous Flomax use regardless of sex. Case 2 is a 75-year-old patient who was referred for routine cataract surgery. He had a history of benign prostatic hypertrophy and kept a detailed medical record that indicated that he had used Flomax 3 years earlier for only 1 week before discontinuing the drug. No other a-blocker was substituted, which was confirmed by his urologist. In the operating room, his pupils failed to dilate beyond 4.0 mm and the iris behavior was consistent with IFIS. The surgeon encountered exactly the same behavior during cataract surgery in the fellow eye 2 months later. This case illustrates that, in some patients, only a short period of time is required for Flomax to cause iris changes leading to IFIS. Moreover, the loss of iris tone does not seem to recover despite a period of years off the medication.
ROBERT H. OSHER, MD Cincinnati, Ohio, USA REFERENCE 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31:664–673
Biaxial phacoemulsification I agree with Arshinoff’s1 comments that the terms bimanual phacoemulsification and microincision phacoemulsification (also known as MICS) do not appropriately describe noncoaxial phacoemulsification. As Arshinoff stated, even with coaxial phacoemulsification, as most of us have been operating for many years with both hands, the standard coaxial procedure has been bimanual. As the new technique of unsleeved phacoemulsification has been introduced over the past few years, it has been referred to by various names by various surgeons, including cold phacoemulsification (which it actually is not). The new unsleeved phacoemulsification procedure has also allowed (actually required) phacoemulsification through a smaller incision. It appears our goal is to try to agree on 1 term for the new procedure. If our goal is to emphasize the unsleeving and if phacoemulsification and aspiration are considered 1 axis and the now-separated irrigation a second axis, then biaxial (as proposed by Arshinoff) would be an appropriate term for the procedure. If, however, we want to emphasize the smaller incision (1.5 mm as opposed to 2.8 mm), then the new procedure could appropriately be called microincision phacoemulsification (or MICSdmicroincision cataract surgery, as proposed by Alio´). When discussing incision length, I have always distinguished the various lengths by the following terms: long incision for extracapsular cataract extraction/intracapsular cataract extraction (10 mm incision), small incision for phacoemulsification with a poly(methyl methacrylate) intraocular lens (IOL) (6 mm incision), miniincision for phacoemulsification with a foldable IOL (3 mm incision), and microincision for phacoemulsification with a foldable IOL (1.5 mm or less incision).
J CATARACT REFRACT SURG - VOL 32, APRIL 2006
547
LETTERS
As the procedure is still in evolution, some cases are performed using unsleeved phacoemulsification through 2 1.5 mm incisions with IOL implantation through an enlarged (or separate) 2.8 mm incision. In this case, one could describe the procedure as biaxial phacoemulsification or microincision phacoemulsification but could not truly call the whole procedure microincision, as only the phacoemulsification portion was performed through a microincision. Only when both phacoemulsification and IOL implantation are performed through 1.5 mm incisions can we truly call the entire procedure microincision. Even this is questionable, as previously pointed out by Osher. If 2 1.5 mm incisions (totaling 3.0 mm of incision length) are used, is it really microincision surgery? If one incision is enlarged to 2.8 mm and the other is left at 1.5 mm (totaling 4.3 mm), is it miniincision surgery? Worse yet, what would a small-pupil biaxial microincision phacoemulsification case (such as in a patient on tamsulosin) that has 2 1.5 mm incisions, 4 0.5 mm incisions for iris hooks, and 1 separate 2.8 mm incision for IOL implantation (7 incisions totaling 7.8 mm) be called? To further confuse the terminology issue, Akahoshi is now performing 1.7 mm (microincision) sleeved coaxial phacoemulsification with IOL implantation through a 1.8 mm incisiondis this coaxial microincision surgery? It would seem appropriate to describe our procedures using both the phacoemulsification technique (coaxial or biaxial) and the incision size (as determined by the IOL technique), such as coaxial miniincision or biaxial microincision. Obviously, we are having fun and enjoying our new and exciting technology and terminology. Only time will tell if these newer smaller-incision, coolertip technique changes will persist as true benefits to our patients.
Figure 2. Elevating the plunger handle before screwing it corrects it position.
HARRY B. GRABOW, MD Sarasota, Florida, USA Figure 3. The tip of the plunger exerts central rather than tangential force.
REFERENCE 1. Arshinoff SA. Biaxial phacoemulsification [letter]. J Cataract Refract Surg 2005; 31:646–647
Silicone lens fracture using IOL injector The case report by Chuah and Rajesh1 describes an intraoperative fracture of an AMO Clariflex silicone posterior chamber lens using the Allergan intraocular lens injector. While we agree that this was the first reported case in the literature, we certainly encountered similar cases in the past while using the Allergan UNFOLDER
injector Silver Series (model PSHST) with the AMO ClariflexC silicone lens. In our experience, the main reason for the fracture was the shearing force of the injector overriding the lens while screwing the plunger (Figure 1). We found that elevating the plunger compensates for any looseness in the injector handle and depresses the tip into the lens, preventing overriding (Figures 2 and 3). This single change in technique allowed us to avoid this problem in our last 500 cases. We agree with the authors that a small tear in the lens usually causes no problems. BASHAR R. MOHAMMED, MB, CHB STEVE R. PERRY, FRCOPHTH Worcester, United Kingdom REFERENCE 1. Chuah JL, Rajesh CV. Intraoperative fracture of AMO Clariflex silicone posterior chamber IOL [correspondence]. J Cataract Refract Surg 2005; 31:1260–1261
Intraoperative retinoscopy Figure 1. Lens fracture results when the plunger overrides the lens.
548
Ianchulev et al.1 describe the use of intraoperative retinoscopic autorefraction to obtain an estimate of intraocular lens (IOL) power needed at the time of cataract extraction.
J CATARACT REFRACT SURG - VOL 32, APRIL 2006