When doing cataract surgery in patients with floppy iris syndrome, the iris has a tendency to prolapse via the phaco incision. The low iris tone coupled with a pressure gradient causes the iris to become mobile and prolapse through the cornea incision. Certainly, placing iris hooks or rings in the eye can help hold and stabilize the iris during surgery, but at the end of the case these devices must be removed and the incision sealed without entrapment of the iris.
The key to managing this condition is to equalize the pressure gradient that is causing the iris to prolapse. Typically this involves a higher pressure behind the iris and a lower pressure in front of the iris, in the vicinity of the phaco incision. Flattening the anterior chamber and releasing the fluid from behind the iris will result in neutralizing the pressure gradient, and this will allow the iris to spontaneously return to inside the eye.
The incision can then be sealed in this state, with a flat anterior chamber, to ensure that the iris does not get entrapped into the corneal stroma. At this point the anterior chamber can be deepened via the paracentesis, which is then sealed. The incision is carefully checked to make sure that it is completely water-tight. If it leaks, even a little bit, a suture is highly recommended. Any incision leak in the post-op period will likely result in iris being trapped in the incision.
Click below to watch the video showing this technique of incision closure:
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