Management of lens–iris diaphragm retropulsion syndrome

Abstract

We read with keen interest the article on managing the lens–iris diaphragm retropulsion syndrome (LIDRS).1 Methods to relieve the block include lowering the bottle height to decrease the pressure gradient between the anterior and posterior chambers and mechanically separating the iris from the anterior capsule rim using the irrigation/aspiration probe, phaco tip, or any second instrument. We recently encountered several cases of LIDRS because of the many high myopes in our population. Using the technique described by Cionni and coauthors, we failed to relieve the negative pupil block despite sweeping the iris off the anterior capsule. We had to aspirate the ophthalmic viscosurgical device (OVD) over the iris in at least 1 quadrant before we succeeded in breaking the block. Loose zonules, 360-degree overlap of the anterior capsule and the iris, along with the mechanical push by the dispersive OVD contributed to the failure of the maneuver to relieve the LIDRS. Cionni and coauthors used the soft-shell technique with sodium hyaluronate 1.0% (Provisc) in the center and sodium hyaluronate 3.0%–sodium chondroitin sulfate 4.0% (Viscoat) in the periphery. While Provisc is easily removed at the start of phacoemulsification, Viscoat is left coating the endothelium and the iris periphery, making it easier to release the iris–anterior capsule apposition with manual manipulation alone. In our center, it is customary to use Viscoat alone during phacoemulsification. This dispersive OVD tends to push the iris posteriorly, plastering it against the anterior capsule where the capsulorhexis touches the undersurface of the pupil, thereby counteracting the maneuvers to separate the iris and the anterior capsule. The maneuver described by Cionni and coauthors may be useful for surgeons using the soft-shell technique, whereas the removal of OVD in at least 1 quadrant is necessary when dispersive OVDs such as Viscoat and hyaluronate 3.0% (Vitrax) are used. Soon Phaik Chee MBBS, FRCSG, MMed (Ophth), FRCSE Kristine Bacsal MD, DPBO Singapore