Managing iris prolapse during cataract surgery

requires identifying cause, tailoring solution

Ocular Surgery News U.S. Edition, September 10, 2012Pablo Arregui, MD

One of the more frustrating issues that can happen during cataract surgery is to
have the iris prolapse out of the incision. This can turn a simple surgery into a
complicated one or at the very least alter the appearance of the eye
postoperatively.

Ultimately, the reason the iris prolapses out of the wound is that the pressure
behind the iris is greater than the pressure in front of the iris. The iris is simply
following the pressure gradient. To solve this problem, one needs to identify the
cause and then equalize or reverse this pressure gradient.

Causes of iris prolapse

Fortunately, when the iris prolapses, the surgeon usually has time to evaluate the
situation and determine the underlying cause. Some of the most common causes
are overly aggressive hydrodissection (balanced salt solution trapped behind the
lens), ophthalmic viscosurgical device (OVD) behind the IOL (during IOL
insertion), balanced salt solution misdirection, and intraoperative floppy iris
syndrome (IFIS). Other causes include poorly dilated pupils (more exposed iris
to flip up and out of the wound), hydrated vitreous (from a ruptured capsule or
balanced salt solution getting pushed through the zonules; usually seen with a
dispersive OVD), leaking or poor wound construction, patient Valsalva
maneuver (from pain or a lid speculum that is too tight), traumatized or
abnormal iris, suprachoroidal hemorrhage (entailing more to worry about than
the iris), excessive retrobulbar anesthetic, and shallow anterior chambers.

Solutions to iris prolapse

Instinctively, one usually wants to push the iris back into the anterior chamber
through the primary incision. This urge must be resisted. Not only will this
maneuver likely traumatize the iris, but the iris prolapse will almost always
recur because the underlying problem of the pressure gradient has not been
corrected. By identifying the specific cause, one can tailor the solution. The one
common factor is that the treatment will very seldom involve going through the
primary incision. Let us look at some of the more common causes and their
specific solutions. With overly aggressive hydrodissection, excess balanced salt
solution can become trapped behind the lens. This will cause the lens to come
forward and push the iris forward along with it. To resolve this, the surgeon
needs to get the excess balanced salt solution that is behind the lens to come
forward. This is most easily achieved by entering through the paracentesis
incision and pressing posteriorly on the lens and rocking it back and forth. This
allows the balanced salt solution to escape into the anterior chamber and
equalizes the pressure gradient. It helps to put a little posterior pressure on the
paracentesis incision so that as the excess balanced salt solution comes forward,
it can exit the eye.

Misdirected balanced salt solution is one of the most common causes of iris
prolapse but also one of the easiest to treat. It usually happens when the phaco
handpiece is too vertical and too close to the pupillary margin. When balanced
salt solution gets directed behind the iris and pushes it forward, the act of the
iris prolapsing forward usually self-corrects the pressure gradient. To ensure that
it stays this way, pressing posteriorly on the paracentesis incision helps decrease
the overall pressure within the anterior chamber.

There are many excellent articles that address IFIS. Not every patient on an
alpha-adrenergic blocker will develop intraoperative iris problems. When they
do arise, the most effective options are using Shugarcaine 4% unpreserved
lidocaine diluted with BSS Plus (Alcon) in mild cases or iris hooks or rings
in more severe cases. Sometimes, preoperative treatment with a long-acting
dilating agent is also useful. In these cases, one wants to be careful that the
incision is meticulously constructed, is located slightly more anteriorly, and is a
little longer than usual.

Hydrated vitreous is sometimes seen with the use of dispersive OVDs. Balanced
salt solution can be trapped and directed backward through the zonules by a
dispersive OVD, which then pushes the lens and the iris diaphragm forward.
Sometimes this can be difficult to identify or distinguish from other causes. To
resolve this, one needs to enter through the paracentesis and burp out some of
the OVD. This creates additional potential space in the anterior chamber and
allows the balanced salt solution that is trapped behind the iris to come forward.
Incidentally, if the iris and lens are coming forward and rocking the lens does
not solve the iris prolapse problem, it is probably due to dispersive OVD
pushing the lens and iris forward rather than balanced salt solution trapped
behind the lens. Many surgeons who prefer dispersive OVDs like to burp a
small amount out of the eye prior to doing their hydrodissection to create more
space in the anterior chamber. This is why a soft-shell technique is usually
preferred with a cohesive OVD, such as Healon (sodium hyaluronate, Abbott
Medical Optics). The cohesive OVD in the soft-shell technique is much less
likely to force the balanced salt solution posteriorly.

If there is significant wound leak or faulty construction, one can sometimes

place a suture near the edge of the incision to effectively shorten it and
minimize the problem. If this does not work, do not hesitate to abandon the
incision and move 90 away to create a better incision. Of course, this may alter
plans for astigmatic correction. If the patient is making Valsalva maneuvers, it is
usually due to pain (have the anesthetist help with this) or could be because the
lid speculum is too tight.

In previously traumatized eyes with prior iris damage or abnormal irises due to
some other medical condition, consider using iris hooks or an iris ring early in
the procedure. In some cases, using micro-scissors to cut any strands that might
get caught in the phaco tip or irrigation and aspiration handpiece minimizes the
damage. (It was not long ago that cutting the prolapsed iris and repositing the
remains was considered an acceptable solution.) With shallow anterior
chambers, consider preoperative Diamox (acetazolamide, Duramed
Pharmaceuticals) and mannitol or a pars plana vitrectomy. Sometimes in
extreme cases, a peripheral iridectomy can be performed to equalize the
pressure gradient.

Finishing the procedure

Even after the cause has been identified and the problem has been corrected,
sometimes the iris remains stuck in the incision. If this happens, use a
cyclodialysis spatula or some other blunt instrument through the paracentesis
incision to gently reposition the iris. If it does not easily return to its anatomic
position, the problem has not been identified or fully corrected. Once the iris is
 back in position, it is critical to avoid having this problem recur. For most of
these causes, once the problem has been identified and treated, the iris will no
longer continue prolapsing out of the wound. If it does, consider lowering the
bottle height and decreasing the flow and vacuum of the phacoemulsification
machine. Additionally, one can add a small amount of dispersive or visco-
adaptive OVD through the paracentesis over the iris prior to inserting any
instrument through the primary incision. This can be done as often as necessary.
Only a small amount of OVD is needed, and one should make certain that the
OVD goes over the peripheral iris and not under it.

Summary

Although iris prolapse does not usually cause significant postoperative visual
problems, one must be aware that this surgical inconvenience can quickly turn
into a surgical disaster. Significant iris damage can lead to a patient with severe
and chronic visual complaints who will revisit the office often, be unhappy and
let other patients know it. If iris prolapse occurs, it is critical to identify the
cause of the problem and treat the specific issue so that the pressure gradient in
front and behind the iris is equalized. Of course, whenever possible, prevention
is the key. Once an iris prolapses, it will have a tendency to prolapse over and
over again. Anticipate and prepare for issues based on the patients medication
list. Make sure the wounds are well constructed. Be careful not to overinflate
the anterior chamber when hydrodissecting, especially with dispersive OVDs.
Make sure the patient is comfortable before the procedure and remains so
throughout the procedure. And of course, use careful surgical technique to
minimize the likelihood of damaging the iris.

References:

Allan BD. Mechanism of iris prolapse: a qualitative analysis and implications for surgical technique. J
Cataract Refract Surg. 1995;21(2):182-186.
Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract
Refract Surg. 2005;31(4):664-673.

Devgan U. Management of iris prolapse during cataract urgery. Ophthalmology

Management. January.2007. http://www.ophthalmologymanagement.com/articleviewer.aspx?articleid=86749

Khng C, Osher RH. Surgical options in the face of positive pressure. J Cataract Refract
Surg. 2006;32(9):1426-1425.