When we encounter iris prolapse in a patient with a light-colored iris, we must be very careful because any iatrogenic damage will be far more visible compared to a dark-colored iris. This damage is more than just cosmetic because it can also allow excessive or stray light to enter the eye, contributing to glare and other dysphotopsias.
This patient has a history of tamsulosin (Flomax) use which contributes to floppy iris syndrome. The young surgeon has completed about 100 cataract surgeries during the past year, so this is very early in the learning curve for phaco. The incision is well-constructed and the capsulorhexis is intact and about 5 mm in diameter. The iris prolapses when too much balanced salt solution is used to hydro-dissect the cataract from the capsular bag.
The Cause: When watching this video, notice how the anterior chamber deepens and the iris bulges forward during hydro-dissection. This is the time to stop and release the trapped fluid. Instead, the surgeon continues the hydro-dissection and then the iris prolapses from the incision.
The Solution: We can release the trapped fluid by lifting the nucleus out of the capsular bag and into the iris plane. This equalizes the pressure gradient and the pupil/iris is now holding the nucleus in position.
The Bonus: To assist in nucleus removal, I use a 27g cannula and the chopper to manually split the cataract into two halves, which are then more easily phaco-aspirated from the eye.
At the end of the case, the resident places a suture to ensure the integrity of the incision. This is highly recommended for the more novice surgeons.
Click below to see the video of iris prolapse in a resident cataract case:
I routinely burped some viscoelastic out before I Hydro dissect to minimize the risk of Iris prolapse and blowing out the post capsule. A Ring would’ve made this a routine case