The Malyugin ring: A useful tool for IFIS

Intraoperative floppy iris syndrome (IFIS) can greatly complicate cataract surgery and put patients at risk of permanent ocular damage. IFIS occurs very often in patients taking α 1A antagonist medications (alpha blockers), such as tamsulosin (Flomax, Astellas) and others. Physicians often prescribe alpha blockers for:

• men with benign prostatic hyperplasia (BPH);
• women with urological issues;
• patients with hypertension.

It is important to note that the longstanding use of tricyclic antidepressives is also clearly linked with IFIS.

Given the ageing of the population – resulting in more cases of BPH, hypertension and other diseases that are often treated with α 1A antagonist medications – IFIS is on the rise. Furthermore, IFIS can occur soon after starting alpha blocker medication, and stopping their use before surgery does not prevent the syndrome from reappearing during surgery.

Surgeons must be aware that a patient who has used these medications in the past, or who currently uses them, is at risk of IFIS. Surprisingly, an estimated 96.8% of primary physicians are unaware of the link between alpha blocking medications and IFIS.

 IFIS and surgical implications

A fast-moving or floppy iris can be obtrusive during surgery in several ways: it can move into the phaco tip and be aspirated, causing a phaco bite, and the iris tissue can move into the paracentesis and the clear corneal cut. These problems can result in further intraoperative and post-operative complications, including inflammation and defects to the iris that might affect the light-adjustability of the iris post-surgery.

The presence of IFIS generally makes it very difficult to carry out a quick, clean surgery, and complication rates can rise up to 15% in these instances

 The Malyugin ring

Fortunately, we already have a device in our toolbox to prevent complications and improve outcomes in patients with IFIS; namely, the Malyugin ring (Microsurgical Technology), which stabilises the iris during surgery.

The use of ophthalmic viscosurgical devices and mechanical pupil dilators has already been described in literature, and as such the Malyugin Ring is a familiar mainstay in ophthalmic surgeries. Composed of a flexible polypropylene polymer, the device is foldable, disposable and easy to implant, requiring no additional cut aside from the standard 2-mm incision.

It does not cause trauma to or stretching of the pupil, nor does it give rise to iris defects. A further advantage is that it is quick to use, only adding a minute or two to the surgery time if the surgeon is familiar with its use.

Surgeons just starting out in practice and low-volume surgeons may have difficulty dealing with cases of IFIS, but it is likely that they are still familiar with this tool. I strongly advise young surgeons to familiarise themselves with it early on in their cataract surgery training, to experience the great advantages of ensuring a stable iris during surgeries with IFIS.

 Use of the Malyugin ring

In my practice, I deal with especially difficult cataract cases; such as patients with posterior iris synechiae and those with mature cataracts in which the iris does not sufficiently dilate. I often use the Malyugin ring in cases where I can identify IFIS in advance.

Prior to surgery, I assess whether the patient is at high risk of IFIS by asking about their medical history and any use of alpha blockers or tricyclic antidepressives. Not all patients who take these medications have IFIS, but if they present high risk then I have the pupil expander on hand for the procedure.

At the beginning of the surgery, I ascertain whether IFIS is present by flushing the anterior chamber with balanced salt solution. This may produce some typical iris vibrations that indicate the presence of IFIS.

If these vibrations are present, I first inject the viscosurgical devices, then I insert the ring before starting phaco modification. It is important to be prepared for its use prior to commencing the surgery in these situations.

 Conclusion

Most ophthalmologists already know how to use the Malyugin ring, and I suggest that they have it on hand for surgeries where IFIS may be present. I also advocate educating primary care physicians about the link between alpha blockers and IFIS to enable them to make better-informed decisions with their patients.

Through a combination of understanding our patients’ medical histories – including past or present use of alpha blockers, or long-term use of tricyclic antidepressives – and making preparations to stabilise the iris when necessary, we can greatly improve surgical outcomes.

Disclosures:

Dr Marc Schargus, FEBO, MHBA
E: M.Schargus@asklepios.com
Dr Schargus is head of the Department of Ophthalmology, Asklepios Clinic North - Heidberg, Hamburg, Germany. He has no financial interests in the products mentioned in this article.

References:

Chang DF. ASCRS White Paper: Clinical review of intraoperative floppy iris syndrome. Journal of Cataract & Refractive Surgery Review/Update (2008).

Nderitu P. Intraoperative floppy iris syndrome and use of chronic oral tricyclic antidepressant. Journal of Cataract & Refractive Surgery Case Report (2016).