This is a very tough case for this senior resident. The patient has a history of chronic uveitis, which has been relatively quiescent for the past few months, combined mechanism glaucoma which required a seton drainage device, and now a dense posterior subscapsular cataract which is hidden behind a small pupil which has extensive synechiae and is covered by a fibrotic membrane.
The iris is atrophic and we are not expecting to regain any iris sphincter muscle function. This means that while we want to expand the pupil to a more normal size, such as 4 mm in diameter, we do not want to stretch or rip the iris with iris hooks or a pupil ring. A pupil expansion ring may give us a 7 mm pupil during the cataract surgery, but the iatrogenic iris trauma may result in a permanent 7 mm mydriatic pupil for life. And this patient is only about 30 years old.
Our technique is to work underneath the iris and this video will show you how. Then at the end of the case we even address the encapsulation of the Ahmed valve footplate and restore flow through the seton. The case goes well and that patient achieves excellent vision and a normal IOP.
click below to watch this video and learn these excellent surgical pearls: