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2780: VIP patient with PXF and IFIS

Close-up image of an eye showing a cataract surgical case in a VIP patient with PXF and IFIS, highlighting maximum dilation achieved without the use of pupil rings or hooks.

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?

video link here

https://youtu.be/oOHKb2NO6-w

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