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Reply: Management of lens–iris diaphragm retropulsion syndrome
LETTERS
anterior capsule rim using the irrigation/aspiration probe, phaco tip, or any second instrument. We recently encountered several cases of LIDRS because of the many high myopes in our population. Using the technique described by Cionni and coauthors, we failed to relieve the negative pupil block despite sweeping the iris off the anterior capsule. We had to aspirate the ophthalmic viscosurgical device (OVD) over the iris in at least 1 quadrant before we succeeded in breaking the block. Loose zonules, 360-degree overlap of the anterior capsule and the iris, along with the mechanical push by the dispersive OVD contributed to the failure of the maneuver to relieve the LIDRS. Cionni and coauthors used the soft-shell technique with sodium hyaluronate 1.0% (Provisc) in the center and sodium hyaluronate 3.0%–sodium chondroitin sulfate 4.0% (Viscoat) in the periphery. While Provisc is easily removed at the start of phacoemulsification, Viscoat is left coating the endothelium and the iris periphery, making it easier to release the iris–anterior capsule apposition with manual manipulation alone. In our center, it is customary to use Viscoat alone during phacoemulsification. This dispersive OVD tends to push the iris posteriorly, plastering it against the anterior capsule where the capsulorhexis touches the undersurface of the pupil, thereby counteracting the maneuvers to separate the iris and the anterior capsule. The maneuver described by Cionni and coauthors may be useful for surgeons using the soft-shell technique, whereas the removal of OVD in at least 1 quadrant is necessary when dispersive OVDs such as Viscoat and hyaluronate 3.0% (Vitrax) are used. SOON PHAIK CHEE, MBBS, FRCSG, MMED (OPHTH), FRCSE KRISTINE BACSAL, MD, DPBO Singapore
Reference 1. Cionni RJ, Barros MG, Osher RH. Management of iris– lens diaphragm retropulsion syndrome during phacoemulsification. J Cataract Refract Surg 2004; 30:953–956
Reply:
I agree with these comments. If the chamber is filled completely with Viscoat (or Healon5), it is more difficult to lift the iris off the capsule and relieve the pupil block. However, once the block is relieved, the chamber returns to normal depth.—Robert J. Cionni, MD
W
e read with interest the case report by Cionni and coauthors1 describing a method of managing LIDRS during phacoemulsification. Using microendoscopy, they observed that LIDRS was essentially a reverse pupillary block and could be managed by separating the iris from the anterior capsule rim mechanically with an irrigation/aspiration tip. We also encounter lots of high myopic phacoemulsification in our locality and would like to share our experience in tackling the problem of LIDRS. When the AC deepens in LIDRS, the surgeon’s reflexive action is to lower the infusion bottle height. The decrease in pressure acting on the lens also causes an undesirable reduction in infusion volume. When outflow equals or outstrips inflow, AC turbulence and minicollapses occur and mimic phenomena commonly seen with positive pressure.2 By lifting the iris rim from the residual anterior capsule rim, the reverse pupillary block can be relieved, but the effect may be temporary as the underlying causes such as thinly stretched zonules, underdeveloped ciliary body, and disequilibrium in pressures between chambers are still present. All will result in the fluctuation of AC depths and oscillation of pupil sizes, which may make the surgery difficult and hazardous. We prefer to relieve the reverse pupillary block in a more sustained manner intraoperatively using flexible iris retractors developed by de Juan and Hickingbotham.3 Three of the iris retractors (Alcon/Grieshaber flexible iris retractors 611.65) are inserted, as described by Nichamin,4 and the fourth is placed in the subincisional area just posterior to the corneal phaco incision, as described by Oetting and Omphroy,5 to create a diamond-shaped pupil. By doing this, the iris can be lifted up continuously from the anterior capsule rim to avoid reverse pupillary block and the iris can also be held securely from the wound and phaco probe to minimize the chance of iris prolapse and damage. Alternatively, the reverse pupillary block can be relieved by enlarging the existing continuous curvilinear capsulorhexis (CCC). A small flap at the rim of CCC is created with the cystotome by making a tangential cut and can be grasped and extended with a capsulorhexis forceps. A 7.0 to 8.0 mm diameter CCC is generally large enough to avoid iris–capsule touch. This method is technically more demanding but can be considered a substitute when an iris retractor is not available.
J CATARACT REFRACT SURG—VOL 31, JULY 2005
1273
anterior capsule rim using the irrigation/aspiration probe, phaco tip, or any second instrument. We recently encountered several cases of LIDRS because of the many high myopes in our population. Using the technique described by Cionni and coauthors, we failed to relieve the negative pupil block despite sweeping the iris off the anterior capsule. We had to aspirate the ophthalmic viscosurgical device (OVD) over the iris in at least 1 quadrant before we succeeded in breaking the block. Loose zonules, 360-degree overlap of the anterior capsule and the iris, along with the mechanical push by the dispersive OVD contributed to the failure of the maneuver to relieve the LIDRS. Cionni and coauthors used the soft-shell technique with sodium hyaluronate 1.0% (Provisc) in the center and sodium hyaluronate 3.0%–sodium chondroitin sulfate 4.0% (Viscoat) in the periphery. While Provisc is easily removed at the start of phacoemulsification, Viscoat is left coating the endothelium and the iris periphery, making it easier to release the iris–anterior capsule apposition with manual manipulation alone. In our center, it is customary to use Viscoat alone during phacoemulsification. This dispersive OVD tends to push the iris posteriorly, plastering it against the anterior capsule where the capsulorhexis touches the undersurface of the pupil, thereby counteracting the maneuvers to separate the iris and the anterior capsule. The maneuver described by Cionni and coauthors may be useful for surgeons using the soft-shell technique, whereas the removal of OVD in at least 1 quadrant is necessary when dispersive OVDs such as Viscoat and hyaluronate 3.0% (Vitrax) are used. SOON PHAIK CHEE, MBBS, FRCSG, MMED (OPHTH), FRCSE KRISTINE BACSAL, MD, DPBO Singapore
Reference 1. Cionni RJ, Barros MG, Osher RH. Management of iris– lens diaphragm retropulsion syndrome during phacoemulsification. J Cataract Refract Surg 2004; 30:953–956
Reply:
I agree with these comments. If the chamber is filled completely with Viscoat (or Healon5), it is more difficult to lift the iris off the capsule and relieve the pupil block. However, once the block is relieved, the chamber returns to normal depth.—Robert J. Cionni, MD
W
e read with interest the case report by Cionni and coauthors1 describing a method of managing LIDRS during phacoemulsification. Using microendoscopy, they observed that LIDRS was essentially a reverse pupillary block and could be managed by separating the iris from the anterior capsule rim mechanically with an irrigation/aspiration tip. We also encounter lots of high myopic phacoemulsification in our locality and would like to share our experience in tackling the problem of LIDRS. When the AC deepens in LIDRS, the surgeon’s reflexive action is to lower the infusion bottle height. The decrease in pressure acting on the lens also causes an undesirable reduction in infusion volume. When outflow equals or outstrips inflow, AC turbulence and minicollapses occur and mimic phenomena commonly seen with positive pressure.2 By lifting the iris rim from the residual anterior capsule rim, the reverse pupillary block can be relieved, but the effect may be temporary as the underlying causes such as thinly stretched zonules, underdeveloped ciliary body, and disequilibrium in pressures between chambers are still present. All will result in the fluctuation of AC depths and oscillation of pupil sizes, which may make the surgery difficult and hazardous. We prefer to relieve the reverse pupillary block in a more sustained manner intraoperatively using flexible iris retractors developed by de Juan and Hickingbotham.3 Three of the iris retractors (Alcon/Grieshaber flexible iris retractors 611.65) are inserted, as described by Nichamin,4 and the fourth is placed in the subincisional area just posterior to the corneal phaco incision, as described by Oetting and Omphroy,5 to create a diamond-shaped pupil. By doing this, the iris can be lifted up continuously from the anterior capsule rim to avoid reverse pupillary block and the iris can also be held securely from the wound and phaco probe to minimize the chance of iris prolapse and damage. Alternatively, the reverse pupillary block can be relieved by enlarging the existing continuous curvilinear capsulorhexis (CCC). A small flap at the rim of CCC is created with the cystotome by making a tangential cut and can be grasped and extended with a capsulorhexis forceps. A 7.0 to 8.0 mm diameter CCC is generally large enough to avoid iris–capsule touch. This method is technically more demanding but can be considered a substitute when an iris retractor is not available.
J CATARACT REFRACT SURG—VOL 31, JULY 2005
1273