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BLOG: Calling for ring expansion — We have another small pupil
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Just like in life, the old saying of “when it rains, it pours” exists in cataract surgery. It is not uncommon when planning on how to perform cataract extraction in a patient with a dense lens that we also encounter other complicating factors. These include smaller pupils that poorly dilate even with pharmacological and mechanical means of stretching, adhere to the anterior capsule of the lens with posterior synechiae and/or demonstrate floppy iris syndrome. To further increase the level of difficulty, these types of cataracts are seen in patients with weak or loose zonules of the lens and delicate endothelium of the cornea.
When confronted with this type of challenging case, any additional tool in the armamentarium that decreases surgical time and maneuvers in an easy manner would improve the chances of success and be welcomed in the operating room. One effective way to do this is to have better pupillary dilation. In the past, options for dilation included mechanical stretching or the use of iris hooks. Although these choices provided dilation, they can be time-consuming and also cause permanent damage to the iris tissue.
New approaches have included the use of intraocular rings to aid in small pupil cases. One new tool that I have found to be excellent is the I-Ring pupil expander (Beaver-Visitec). There are five characteristics I have found useful in particular for my challenging cases:
1. Ease of placement . The ring inserts through a clear corneal incision created in cataract surgery and done single-handedly. The ring material is soft yet sturdy, made from polyurethane. It can easily be maneuvered into position with the use of a Sinskey hook at the four available positioning hooks located just inside the channels. The Sinskey hook never touches the iris.
2. Ease of removal. The ring can be disengaged from the iris again with the aid of a Sinskey hook. It is then removed from the eye by simply overlapping the prongs from the shooter over one of the four available hinges located next to each channel and retracted into the shooter.
3. Ease of visibility. The ring is a solid green color that provides contrast to easily identify it even if there is blood or capsular staining dye in the anterior chamber.
4. Provides efficient dilation. The ring provides an even dilation of 6.3 mm, which provides access to the underlying anterior capsule and can used as a reference when performing capsulorrhexis.
5. Atraumatic to the iris. The ring has four channels that push the iris tissue in order to expand but not pinch it. This is especially important because there are no focal areas of iris that receive significant force during surgery even if the ring is moved or at the end of the case when it is removed. This reduces the risk of distorting or even tearing the iris tissue.
As cataract surgery evolves, both our patients’ and our own expectations increase. However, challenging cases are still present. The use of products like the I-Ring aid the surgeon intraoperatively and the patient postoperatively.
Disclosure: Teymoorian reports no relevant financial disclosures.