In this case I need to perform cataract surgery in a VIP patient with a 4 mm pupil, blue iris, pseudo-exfoliation and Intraoperative Floppy Iris Syndrome (IFIS), while avoiding pupil expansion rings or hooks. In this setting, after pharmacologic dilation and intracameral mydriatics, I fill the chamber with a dispersive viscoelastic combination to visco-dilate the pupil (Osher’s visco-mydriasis technique). Then, trusting that a 4 mm pupil can safely support a larger capsulorhexis, I perform a 5.0–5.5 mm capsulorhexis even without fully visualizing the entire edge. For nuclear removal, I bring the nucleus partially out of the bag using gentle hydro-dissection, then elevate the nucleus into the iris plane so the iris itself helps cradle it during chopping/emulsification. I maintain ultra-low fluidics, low vacuum and bottle height to minimize iris billowing, avoid stress on zonules in pseudo-exfoliation, and use a non-rotational or minimal-rotation phaco strategy. After cortical cleanup (using gentle, tangential striping), injecting fresh OVD before IOL insertion to maintain chamber depth and protect the floppy iris during lens placement. This “no-ring / no-hook” technique demands patience, meticulous fluidics, and confidence but when expertly executed even challenging IFIS + PXF + small-pupil cases can be done elegantly and safely. What is your technique for these cases?
Dear Dr Devgan,
My name is Henri Buhagiar and I have retired after 37 years in Ophthalmology, from Allergan, AMO, Abbott and J&J. I started in the early days of Phaco and foldable lenses back in 1988 in Australia/ New Zeala d
You sent a video and also a comment that I received in a career book that I was sent.
I have been a strong advocate of your videos, passing them on the surgeons and company reps. They are informative, succinct and most of all genuine cases and what can go wrong. Event though I have now “ Hung my boots up”, I still receive and watch your videos.
For this I thank you. Have a safe and happy holiday season
Henri
thank you for the kind words and for enjoying the Cataract Coach videos 🙂