FP602 : Intracameral Adrenaline and Low Parameters v/s Iris hooks/Malyugin ring in IFIS – A Comparative Study

Dr. Sangeeta Kalita, K18831, Dr. Ratish Chandra Paul

INTRODUCTION-(IFIS)¹  is the condition characterized by 3 intraoperative features-

1. Flaccid iris stroma that undulates and billows in response to intraocular fluid currents
2. A propensity for the floppy iris stroma to prolapse toward the phacoemulsification and side-port incisions despite proper wound construction
3.  Progressive intraoperative pupil constriction despite standard preventive preoperative pharmacologic measures.

The conventional methods of pupil stretching and partial-thickness sphincterotomies – worsens the situation of achieving mydriasis² in IFIS.

Hence, in this study, attempt is done to determine whether epinephrine injected directly into the anterior chamber would be beneficial in these IFIS cases.

AIMS AND OBJECTIVES–

• To compare the safety and efficacy of intracameral adrenaline and low parameters (Group I). Vis-a-vis hooks and rings (Group II) in intraoperative floppy iris syndrome(IFIS) patients undergoing cataract surgery
• To compare final visual outcome in two groups.

MATERIALS AND METHODS–

• Study design- Retrospective study
• Study duration- 1 year (September, 2015- August, 2016)
• Study setting- single surgeon, a tertiary level eye care centre, Kolkata, India.
• Methodology – Cataract patients with a recorded IFIS of any severity occurring over this period- identified by electronic OP-recording software & enrolled in a multivariate analysis

Group I-IFIS patients with cataract removal using intracameral adrenaline combined with low parameters during phacoemulsification.

Group II-   IFIS patients with cataract removalusing iris hooks and malyugin rings.

 

Final visual outcome was determined and compared between the two groups based on-

• Best corrected distant visual acuity
• PCR(posterior capsular rent) incidence during surgery
• Other complications(iris injury, iris shafing).

 RESULTS AND OBSERVATIONS–

• IFIS was observed in 123 out of totally 6120 eyes (2%)
• Male prepon derance more than females 4:1
• Mean age group is 70.5 years.
• Use of tamsulosin , an apha1 adrenergic antagonist used in the treatment of benign prostatic hyperplasia found to be the major cause in IFIS patients.

 

 

• Mean preoperative pupil diameter in this study is 5.3mm. mean preoperative pupil diameter in group 1 is 5.5mm and that in group2 is 5mm.
• Higher rate of PCR incidence noted in group 2 (p>0.05). higher rate of other complications like iris trauma, sphincter tear, iridocyclitis, and cystoid macular oedema noted in group 2patients.

 

• Mean final visual acuity is found to be better in group 1 patients.

DISCUSSION-

In our study, in Group I, we used

• intracameral adrenaline(1:2000). it

à dilates pupil

à impede access of instrumentation,

à reduces billowing & the tendency for prolapse

or further miosis

   Joel Shugar, MD, this dilution raised the acidic pH of the stock epinephrine solution to physiologic levels without evidence of endothelial toxicity.

• Aspiration flow rate(15-20 cc/min)
• Vacuum(250 mmHg)
• 60-70 cm bottle height
• High viscosity OVD s(Viscoat)

àdecreases the risk for iris related problems, produces viscomydriasis

à prolongs the presence of Viscoat in the anterior    chamber

• In Group II (iris retractors and the Malyugin ring)– 100% assurance that the pupil will be adequately large

Disadvantage- risk of accidental corneal/ incisional

trauma

–  does not impede instruments’ access to

the lens

– depigmentation and damage to the

sphincter (minimal with Malyugin ring)

– expensive

• More than 90% patients had mild to moderate grade IFIS.
• Mean age group in our study is 70.5 years.
• Mean preoperative pupil diameter is 5mm, however mean pre op PD in grp1 found to be 5.5mm , and mean preop PD is 5mm in grp2.
• Use of iris hooks/Malyugin ring provided stable intraoperative pupil diameter, though there is a risk of iris trauma.sphincter tears more common with use of iris hooks.Malyugin device was faster and easier to insert,though there is risk of endothelial injury due to their girth,rigidity and manipulation in Anterior chamber.

 

CONCLUSION-

• Early diagnosis of IFIS reduces intraoperative complication rate & affect final visual outcome
• Drug history awareness-

à α₁– antagonist intake for BPH (male)

à AT1-receptor antagonists  for hypertension & benzodiazepines for anxiety disorder

• Preoperative usage of intracameral adrenaline & low parameters- safe, good efficacy & cost-effective for cataract removal in IFIS .