The combination of 1.8 mm coaxial micro-incision cataract surgery (C-MICS), proper wound construction, and attention to other
elements of surgical technique aiming to maintain chamber stability allows safe and effective cataract surgery in eyes with
intraoperative floppy iris syndrome (IFIS) without the need for pupil expansion, according to Dr John D. Hunkeler.
Dr Hunkeler described his personal experience performing 1.8 mm C-MICS with linear phacoemsulfication using a proprietary
phacoemulsification system (Stellaris Vision Enhancement System, Bausch + Lomb) in a presentation at the annual meeting of
the European Society of Cataract and Refractive Surgeons.
Key components of his technique include the creation and maintenance of snug trapezoidal incisions, use of a smaller capsulorhexis
than usual, and a divideandconquer approach.
"The snug trapezoidal incisions help reduce turbulence and prevent iris prolapse, and I create a relatively small capsulorhexis
of 4 to 5 mm because these eyes have small pupils," explained Dr Hunkeler, medical director, Hunkeler Eye Institute, Kansas
City, and former chairman, department of ophthalmology, University of Kansas School of Medicine, Kansas City, Kansas, USA.
"The divide-and-conquer technique keeps the phaco tip behind the iris during nuclear disassembly to reduce the likelihood
of iris trauma," he said. "Nuclear fragments are elevated into the anterior chamber by the phaco tip in aspiration mode for
subsequent ultrasound removal, well away from the iris. 1.8 mm C-MICS with the [phaco] platform delivers reliable control
of both phaco power and vacuum to maintain excellent chamber stability."
Less need for expansion devices
"Using this procedure I have been able to perform cataract surgery safely and successfully in eyes with IFIS, with no iris
or capsule complications and without the need for pupil expansion devices in most cases," Dr Hunkeler added.
He reported that in 2008, when performing 2.8 mm coaxial phaco, he placed a pupil expansion device (Malyugin ring, MicroSurgical
Technology) in 33% of IFIS cataract surgery cases. In 2009, his usage of the device in IFIS cases decreased to 9%, but those
cases were mostly performed during the first half of the year.
"Since August 2009, I have only used the ring in a single IFIS cataract surgery case," he said.
Trapezoidal incision, paracentesis
Dr Hunkeler said he creates a clear corneal trapezoidal incision and a trapezoidal paracentesis, employing a paracentesis
blade first to create the primary incision and then a triangular blade to create the trapezoidal component.
He said he also instills Shugarcaine and Amvisc Plus to help maintain maximum pupillary dilation throughout the procedure.
Using the divide-and-conquer technique, because it reduces the possibility of iris prolapse, he performs as much sculpting
and cracking as possible in the posterior chamber before elevating the lens material to just above the pupillary plane, where
it is removed with C-MICS phaco and irrigation/aspiration.
Once lens removal is completed, viscoelastic is instilled into the posterior chamber, and Dr Hunkeler implants a spherical,
aberration-free microincision lens (Akreos MICS IOL, Bausch + Lomb) through the 1.8 mm clear corneal incision.
Special Contributor
Dr John D. Hunkeler is medical director at the Hunkeler Eye Institute, Kansas City and is the former chairman of the department of ophthalmology
at the University of Kansas School of Medicine, Kansas City, Kansas, USA. He can be contacted via Email: jhunkeler@hunkeler.com
Dr Hunkeler is a consultant to Abbott Medical Optics and Bausch + Lomb.
