Surgical strategies for small pupils - Malyugin Ring

Boris Malyugin
S.FYODOROV EYE MICROSURGERY COMPLEX
MOSCOW, RUSSIA
MALYUGIN RING PEARLS

WHAT IS THE CRITICAL DIAMETER
FOR THE PUPIL
TO BE CONSIDERED “SMALL”?
S. Fyodorov Eye Microsurgery Complex Federal State Institution, Moscow, Russia

4.0 mm3.0 mm2.0 mm
SMALL PUPIL ???

PUPIL SIZE IS RELATIVE
TO:
SURGEON’S SKILL AND TECHNIQUE
INTRAOPERATIVE SITUATION
IRIS TISSUE PROPERTIES

MOST COMMON MECHANISMS
OF SMALL PUPIL FORMATION
ETIOLOGY MECHANISM
AGE-RELATED
PEX
IFIS
DIABETES
POST. SYNECHIAE
IRIS ATROPHY
IRIS DILATOR AND SPHINCTER
MUSCLES ATROPHY
DILATOR MUSCLE ATONY-ATROPHY
METABOLIC CHANGES, RUBEOSIS
UVEITIS, ANGLE CLOSURE
GLAUCOMA, PREVIOUS SURGERY

SURGEON’S SKILL & TECHNIQUE
USE VISCOADAPTIVE OVDs
DECREASE FLUIDIC
PARAMETERS
UTILIZE CHOP
MANIPULATE IN THE AC
CENTER
USE BIMANUAL IA

TECHNICAL CHALLENGES
OF SMALL PUPIL PHACO SURGERY
REDUCED RED REFLEX
INCREASED RISK OF IRIS DAMAGE
IRIS BLEEDING
IRIS PROLAPSE FROM WOUND(S)
SMALL ANTERIOR CAPSULORHEXIS SIZE
- ANTERIOR CAPSULE DAMAGE (CHOPPER, US TIP)
- HIGHER RISK OF POSTOP CAPSULAR PHYMOSIS
INCOMPLETE EVACUATION OF THE CORTICAL
MATERIAL
PROBLEMS IN ENSURING IN-THE-BAG IOL PLACEMENT
ISSUES WITH PROPER ALIGNMENT OF TORIC IOLs

CONSEQUENCES
OF SMALL PUPIL PHACO SURGERY

INTRAOPERATIVE
FLOPPY IRIS SYNDROME
(IFIS)
PROGRESSIVE PUPILLARY
CONSTRICTION DURING
SURGERY
A MARKED PROPENSITY FOR
THE IRIS TO PROLAPSE TO THE
PHACO AND SIDEPORT
INCISIONS
FLOPPY IRIS THAT BILLOWS
IN RESPONSE
TO NORMAL IRRIGATING
CURRENTS IN THE AC
J.CAMPBELL, D.CHANG (2004)

Santanella RM, et al. The effect of α1a- adrenergetic receptor antagonist Tamsulosin
(Flomax) on the iris dilator muscle anatomy.
Ophthalmology 2010, May
IRIS DILATOR SMOOTH MUSCLE
Control subject Tamsulosin subject
Control (26 eyes) 8.50 ± 1.61 μm
Tamsulosin (25 eyes) 6.53 ± 1.99 μm (p<0.006)
52 cadaveric eyes from 27 male patients

KEY POINTS
FOR THE DECISION MAKING
PUPIL DIAMETER
BIOMECHANICAL PROPERTIES OF THE
IRIS TISSUE

THE STEP-WISE APPROACH IN
MANAGING SMALL PUPILS
PHENYLEPHRYNE / EPINEPHRINE
INTRACAMERAL INJECTION
VISCODILATATION
POSTERIOR SYNECHIOLYSIS
PUPIL STRETCHING TECHNIQUE
PUPIL EXPANDER DEVICES

STEP-WISE APPROACH

INTRACAMERAL MYDRIARTICS
LIDOCAINE / EPINEPHRINE MIXTURE (EPI-SUGARCAINE)
Sugar JK. Use of epinephrine for IFIS prophylaxis. JCRS 2006 32(7): 1074-1075
9 cc BSS Plus
3 cc 4% Lidocaine (preservative-free)
4 cc 1:1000 Epinephrine (bisulfite-free)
2.5% PRESERVATIVE-FREE EPINEPHRINE (Minims)
1:1000 (1 mg/ml) EPINEPHRINE
(in glass vial containing bisulfite 0.1%)
diluted x4 times with BSS/BSS Plus

PUPIL EXPANSION DEVICES
METAL HOOKS
PLASTIC HOOKS
IRIS RING (MORCHER)
PERFECT PUPIL (MILVELLA)
GRAETHER EXPANDER
SIEPSER RING
MALYUGIN RING (MST)

IRIS HOOKS

IRIS HOOKS
Significant advantage: possibility to fixate the iris and the capsule to the limbus

8
IRIS HOOKS
PERIMETER OF THE SQUARE > PERIMETER OF THE CIRCLE

PERFECT PUPIL (Milvella Ltd.) 5S RING (Morcher GmbH)
GRAETHER RING (Eagle Vision Inc.)
CLARKE RING
Main advantages of pupil expander rings: placement through the
main incision (multiple additional paracentheses aren’t
necessary); protection of the iris margin; prevention of iris
sphincter overstretching.

PAPER CLIP
IRIS FIXATION MECHANISM

6.25 mm
• LESS STRESS TO THE IRIS TISSUE
• EASIER TO IMPLANT AND REMOVE
• BETTER FOR SMALL EYES
5-0 POLYPROPYLENE

5-0 POLYPROPYLENE
7.0 mm
• IFIS CASES - PUPIL STARTS OF BIGGER
• CERTAIN PHACO TECHNIQUES - FLIP,
DIVIDE&CONQUER, etc
• IOL DESIGN AND IMPLANTATION METHOD

ADVANTAGES
8 FIXATION POINTS
ABSENCE OF SHARP EDGES
MINIMAL TRAUMA TO THE IRIS TISSUE
RELIABLE CLAMPING MECHANISM
FLEXIBILITY
INJECTABILITY
LOW PROFILE

SURGICAL TECHNIQUE

IMPLANTATION PEARLS
OPERATING UNDER TOPICAL –
INJECT LIDOCAINE + PHENYLEPHRINE INTO AC
DO NOT OVERFILL A/C WITH OVD
POSITION INJECTOR TIP CLOSE TO THE IRIS MARGIN
SLOWLY WITHDRAW THE INSERTER WHILE
EXPELLING THE RING

>2.2 mm incision
SURGICAL TECHNIQUE
with

IMPLANTATION PEARLS
IF THE PUPIL IS TOO SMALL:
- TRY TO STRETCH FIRST
- USE BIMANUAL TECHNIQUE WHILE ENGAGING
THE SCROLLS
IF THE PUPIL IS SMALL AND/OR ANTERIOR LENS
SURFACE IS PROLATE:
IT IS HARD TO ENGAGE BOTH LATERAL SCROLLS WHILE
INJECTING - HELP WITH THE SIDEPORT INSTRUMENT (OSHER/
MALYUGIN RING MANIPULATOR, LESTER OR KUGLEN HOOK)

=2.2 mm incision
SURGICAL TECHNIQUE
with

REMOVAL PEARLS
DISENGAGE AT LEAST 2 SCROLLS (DISTAL & PROXMAL)
DISPLACE THE RING A BIT DOWN FROM THE INCISION
USE THE 2ND INSTRUMENT HELP TO POSITION THE
PROXIMAL SCROLL ON THE INJECTOR PLATE
IF HARD TO ACCESS THE PROXIMAL SCROLL UNDER
THE MAIN INCISION – ROTATE THE RING CLOCKWISE
WHILE WITHDRAWING – PRESS ON BOTH LATERAL
SCROLLS AS THEY MERGE TOGETHER

SURGICAL TECHNIQUE
TIP: DISENGAGE DISTAL SCROLL FIRST

1.8 mm incision
SURGICAL TECHNIQUE
with

1.8 mm MICS PEARLS
INSERTER DOES NOT ENTER THE CORNEAL TUNNEL
(WOUND-ASSISTED INJECTION)
IN MOST CASES NOT POSSIBLE TO ENGAGE THE DISTAL AND
LATERAL SCROLLS – LAY THE RING FLAT ON THE IRIS
USE SIDEPORT INSTRUMENT TO POSITION THE SCROLLS
ONE BY ONE (BETTER COUNTERCLOCKWISE)
INSERT OPPOSITE SCROLLS FIRST
WHILE REMOVING – DEPRESS THE INTERNAL LIP OF THE
CORNEAL INCISION TO AVOID CATCHING IT WITH THE RIGHT
LATERAL SCROLL

in FLACS

Incomplete capsulotomy using femtosecond laser with a pupil expansion device
JCRS 2014, Volume 40, Issue 4, P. 513-694

CONCLUSIONS
IN SMALL PUPIL CASES MY RECOMMENDATION IS TO FOLLOW THE
STEPWISE APPROACH
TWO MAIN DRIVERS FOR THE DECISION TO USE PUPIL EXPANDER
DEVICE:
- SIZE OF THE PUPIL
- BIOMECHANICAL PROPERTIES OF THE IRIS
ADDED MANIPULATIONS AND COST OF THE MECHANICAL DEVICE
ARE BY FAR OUTWEIGHTED WITH THE SAFETY ISSUES

Surgical strategies for small pupils - Malyugin Ring

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