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    Case of profound posterior pressure

    Surgeon reflects on how strategies for iris prolapse may improve future outcomes

    While participating in an ORBIS Flying Eye Hospital program in Trujillo, Peru, and operating on an elderly patient with a dense cataract under peribulbar anesthesia, James Lehmann, MD, encountered iris prolapse as soon as he made the paracentesis.

    With 30 local ophthalmologists watching via closed circuit television in the front of the plane, Dr. Lehmann proceeded to go through his usual algorithm of strategies to relieve the underlying posterior pressure and keep the prolapsed iris inside the eye. These included decompression of the anterior chamber, sweeping the iris back into the eye, and moving the phacoemulsification incision site.

    After none of his options worked, he decided to place a pupil ring (Malyugin Ring, MicroSurgical Technology), thinking it would hold back the iris and allow him to proceed with phacoemulsification. As he was maneuvering the device into place, however, the anterior capsule split, creating an 'Argentinean flag' in Northern Peru!  

    Dr. Lehmann, in private practice, San Antonio, TX, said his next thought was, “What else can go wrong?” Fortunately, the answer was “nothing,” and the case was successfully completed when he converted to small incision extracapsular cataract surgery.

    After suturing the phaco incision, creating a scleral tunnel incision, and performing an old-fashioned capsulotomy, Dr. Lehmann removed the iris retention device, prolapsed the nucleus into the anterior chamber, and expressed it manually with a lens loop.

    Case resolved

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