“Fortunately, 96% of the time, that’s reversible with intracameral, preservative-free phenylephrine followed by a dispersive viscoelastic. However, about 4% of the time, it’s not really reversible,” she cautioned.
One pearl she suggested is to avoid femtosecond laser use in higher-risk patients with pre-existing small pupils.
Dr. Donaldson shared the example of cataract surgery in a 4.7-mm pupil with a history of floppy iris syndrome. Uneventful lens fragmentation and capsulotomy were performed, but three minutes later, the pupil went down to 2.5 mm. It did not improve with the use of lidocaine or a dispersive viscoelastic material.
“I did have to put in a Malyugin ring in this case. I would recommend after you make a primary wound, put viscoelastic beneath the iris and lift up the iris to safely place the Malyugin ring without grabbing the edge of the capsule in these FLACS cases,” she said.
Surgeons have a number of additional tools and techniques they can use, including:
> Pretreating with nonsteroidal anti-inflammatory drugs
> Use of ketolorac/phenylephrine injection 1%/0.3% (Omidria, Omeros Corp.)
> Various rings and hooks
> Phaco chop, as discussed by David Chang, MD, San Francisco. “He taught us that chopping can put less energy into the eye with minimal movement in anterior chamber. It can be done with small pupils very safely to minimize lenticular movement, especially in pseudoexfoliation syndrome where we don’t want to have extra stress on the zonules. Phaco chop is an excellent technique in these cases,” Dr. Donaldson said.