This is a very tough case and the iris prolapse and damage is considerable. This is the type of case which gives surgeons nightmares because of the extreme challenge and the multiple complications. Our guest surgeon is a true expert surgeon who has been featured here on CataractCoach before with some amazing cases. He has done tens of thousands of surgeries and prior to this case he had a run of about 1000 cases without significant complications. Remember a nightmare case like this can happen to any surgeon at any time. The original surgery was 57 minutes in length but we have shortened it to 13 minutes in this video. You must watch and learn from this video — I certainly did.
That’s a wild case. For the second eye, I might make a longer tunnel for the CCI. Would also probably get hooks or a ring in right away (video #952) after seeing iris prolapse to the para. Maybe preop atropine and mannitol depending on the patient’s health. Thanks for sharing! Learned a lot.
Hindsight definitely 20/20 here. I think at the first instance of iris prolapse through a paracentesis should have given mannitol and waited 15-20 minutes. If Iris prolapse could be resolved,(maybe with the help of Iris hooks on either side using the needle) then proceed. Opening up the eye for the main incision was definitely a bad decision without being able to resolve the paracentesis problem. I feel pretty confident that you could get the iris back in the eye after mannitol. That could easily take 2030 minutes and still might require a vitreous decompression. I would cancel the case at that point, and come back on another day where mannitol could be given pre op. or MAYBE end of the scheduled cases?). A peribulbar block given in anticipation of a possible vitreous decompression.
But given what would probably be my anxiety level of that time I would prefer to come back on another day, pre-treat myself with Inderol and give myself an hour to do the case.
Next time maybe: Iris stretching, a bit less visco, three-step main incision, Malyugin ring, lower irrigation pressure + less aspiration flow- But as you said, no guarantees… Thanks for the video!
I suggest atropin + NSAID drops three days prior.
https://pubmed.ncbi.nlm.nih.gov/34652535/
then https://pubmed.ncbi.nlm.nih.gov/23890368/
And once you notice IFIS- please stop and tap on the wound to make the eye soft. IOP =0. then wait- the IRIS would return
I think we should not go the second step of a surgery before managing a challenge during first step.Even postponing the surgery could be a good idea.It seems that this was a posterior fluid diversion case.
in such situation, I would be very happy to be able to reach the same result. Thanks for sharing