The iris billowing, iris prolapse, and intraoperative miosis associated with intraoperative floppy-iris syndrome (IFIS) can limit the anterior segment surgeon's ability to perform efficient and safe phacoemulsification.1 Identification of the association between systemic α-antagonists and IFIS has allowed appropriate planning and anticipation of surgical events.2 Several authors have described techniques for approaching these cases.2,3 The Malyugin pupil expansion device, which was recently introduced,4 has become the preferred device for IFIS cases in our training program because of its ease of use and the predictable pupillary aperture. Despite our enthusiasm, we have occasionally observed intraoperative behaviors of the Malyugin ring that can limit safe usage. For example, complete retrieval of the ring into the inserter barrel during ring removal can result in unpredictable and chaotic ring behavior that can damage intraocular structures.
At the time of ring removal, our typical technique begins with disengagement of the distal islet. This allows the ring to move into the distal angle during disengagement of the proximal islet with minimal distortion of subincisional iris and corneal tissue. At this point, the inserter is brought to the main wound where the hook can easily grab the proximal islet. If complete retraction is attempted, the ring can begin to twist. Figure 1, left, shows a ring that spun on the injector, leading to incorporation of the iris in a patient with IFIS. Figure 1, right, shows an IFIS patient in whom the ring spun uncontrollably during attempted complete retraction. This distorted ring-inserter configuration caught the edge of the main wound, making removal impossible without distortion of the cornea and 90-degree rotation of the inserter. To prevent twisting, we recommend partial retraction so the lateral eyelets of the ring are drawn to the inserter barrel but not within the barrel.
In our opinion, the Malyugin ring offers cataract surgeons a reproducible strategy to manage small pupils and IFIS. As Chang5 points out, the ring can be safely removed from the eye even with partial retrieval. Instructional videos circulating on the Internet often show complete retrieval of the ring into the injector prior to ring removal from the eye. We have observed problems with complete retrieval and stress that not only can the Malyugin device be removed from the eye with partial retraction into the inserter, but this should be the preferred technique. In our hands, this adjustment in technique has led to fewer intraoperative problems.
1. 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; ASCRS Cataract Clinical Committee. J Cataract Refract Surg. 2008;34:2153-2162.
2. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg. 2005;31:664-673.
3. Oetting TA, Omphroy LC. Modified technique using flexible iris retractors in clear corneal cataract surgery. J Cataract Refract Surg. 2002;28:596-598.
4. Malyugin B. Small pupil phaco surgery: a new technique. Ann Ophthalmol. 2007;39:185-193.
5. 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.