March 24, 2023

This is a complete cataract case shown start to finish in a patient who has floppy iris syndrome due to prior tamsulosin (Flomax) use for prostate issues. As we know, this medication can cause the iris to become excessively floppy and can lead to iris prolapse and damage. The pupils also do not dilate as well and we must tell patients that even if they stopped taking Flomax years ago, the effect from that drug are permanent despite discontinuing the medication. In this video, I explain all of my pearls for success including what I think the best single bit of advice. my best pearl for flomax or ifas cases you know floppy iris and moderate pupil size can be easily managed so here’s the case patient takes flomax or tamsulosin and does suffer from floppy iron syndrome this is the second eye and we’re starting off by making a presentees and putting in anesthetic and look where i put it a little bit under the

Iris that’s about one percent preservative-free lidocaine you can also put in epinephrine maybe concentration about one to ten thousand and now look at the viscosity that’s your dispersive viscosity doing viscomidriosis so using that viscosity to push that pupil margin expand it just a little bit let’s get our main incision done important to have a good incision

So you don’t get irish prolapse out the incision so good tunnel length taking our time a little bit on the long side which is what i want and i like this with floppy arrows barely nicking those limbo vessels now here’s critical you got to make a big rexus do not make a baby rex here i want the rectus to be at least as big as a pupil that would be exactly five

Millimeters and in fact i’ll make it ever so slightly larger than the pupil so maybe about 5.25 maybe even 5.5 millimeters and you can see that’s going around very nicely look at the pivoting motion that we’re doing to keep this ac formed and prevent loss of viscoelastic here comes the number one pearl you want it here it is hydrodissect slow and steady slow and

Steady keep going keep going keep going until it prolapses partly out of the bag and now here tilt it up look i dig the candle into the nucleus and lift that nucleus up so that the pupil the iris is holding the nucleus for me a little small aliquot of dispersive viscosity to protect that cornea in the center but now time for fako the cataract is actually holding

The iris away it it’s extending and distending even that dilation and holding the arrows into the angle of the eye so i can now work centrally here and chop and now emulsify the cataract very efficiently and you can see the irish wants to move but i’ll just stay central and the nucleus actually help me hold the pupil open and in fact the other way is well the

Iris help to hold the nucleus at the iris plane a little bit more chopping here and then emulsify that nucleus and look at that we’re just about done so you can see how incredibly efficient it is and so here’s the very last heminucular piece again chop it again small pieces take these pieces down look at the placement of the chopper in the safety position i don’t

Want that bag to come up be very cautious here and notice how we’re also operating with the faker probe in the center i’ll bring the piece here with vacuum and i’ll bring it centrally before emulsifying it and now just like that three minutes into the case nucleus is out just like that super efficient now for the cortex removal that should be pretty easy but

You have to make sure that we’re not going to leave any cortex behind so we don’t have maximum dilation here so we’re going to have to use that probe to really get into the angle or the equator of the capsular bag under the angle and make sure that we have all the cortex aspirated removed now if we need to we can use the chopper in the second hand to help lift

Up the iris and give us more visibility and there you go pretty well cleaned up i’ll kind of go around here do a little polishing there’s a big pvd or posterior vitreous attachment you see there in the vitreous cavity we’re obviously not going to worry about that at this point and that looks great nice and clean now when you put the lens in the eye first thing

Is with the cohesiveness glass to get a good fill of the bag deep in the bag itself and now in large enlarge the pupil with more visco medias and now let’s make sure the iol goes in the bag do not let this single piece lens end up in the sulcus or even partly in the sulcus because as you know you’ll get like a ugh syndrome uveitis glaucoma hyphema that’ll be a

Bad situation so let’s put this lens in the bag nice and easy deliver it in there get those haptics open up and we’ll get this lens into the appropriate position here rotating it around making sure it’s in the bag completely and i’m very satisfied with that i’ll take the ia probe in i’m going to get the viscoelastic out from behind the iowa optic and then of

Course we’ll clean it out from the enter chamber so i’ve presented to you here an unedited case start to finish as i like to call it my complete cataract case and you can see that even in a case like this with floppy iris and a max pre-op dilation of maybe four and a half at best five millimeters you can still complete the entire case with zero issues in a very

Efficient manner very safe very controlled manner without having to resort to a pupil expansion ring or iris hooks now at the end here we’ll seal up the decision you can see now the outline of the incision i made it a little bit on the longer side just to make sure it’s going to stay sealed and not allow iris prolapse during the case in case we ran into extreme

Floppiness so washing out the little bit of little strands they’re viscoelastic get those out of the eye and that lens you can see is a edlf lens will make sure that lens is beautifully centered up so that’s my number one pearl that is get a good rex’s and get that nucleus out of the bag

Transcribed from video
CataractCoach 1372: my best pearl for IFIS / floppy iris / Flomax cataract surgery By Uday Devgan