Cataract patients with nondilating pupils are among the most challenging cases in phacoemulsification surgery. If you happen to be performing surgery with a visiting surgeon accompanied by an industry representative in your operating room, and the patient’s pupil does not dilate using standard interventions, these factors can add to your already high stress level.

I recall a particular case in which the routine use of Mydriasert (tropicamide 0.28 mg and phenylephrine HCl 5.4 mg; Thea Pharma GmbH) failed to dilate the pupil. With the mindful eyes of our visitors watching, I progressed along the flowchart we use for treatment of a nondilating pupil, applying the intracameral formula I learned from Jorge L. Alió, MD, PhD, of Alicante, Spain. This combination of cyclopentolate, lidocaine 1%, and phenylephrine, which my nurses call the magic dilating formula, usually expands even the most stubborn nondilating pupil.

A NEW DEVICE

However, the magic dilating formula had met its match this time. As you can imagine, given the nature of this cover focus, the magic dilating formula produced insufficient dilation, and the resulting pupil was too small for the mature cataract we had to manage (video available at eyetube.net/?v=lunef). We progressed further on the flowchart, applying Vision Blue (trypan blue ophthalmic solution; DORC International) to dye the anterior capsule and preparing ourselves to use iris hooks, when the industry representative told me about a new device, the Malyugin Ring (MicroSurgical Technology), for nondilating pupils. This instrument, she explained, does not require additional paracenteses and can be introduced through the main coaxial phaco incision. Much to my excitement, she happened to have a sterile sample with her.

After achieving consensus among my surgical staff, we decided to try the new device. You can watch the placement of my first 6.25-mm Malyugin Ring at eyetube. net/?v=pahob. Even in this earliest case, introducing the Malyugin Ring through a coaxial 2.2-mm incision was easy and straightforward. Using care during insertion (Figure 1), I engaged the distal scroll to catch the iris margin opposite the main incision, atraumatically stretching the pupil.

I continued to introduce the device through the 2.2- mm incision, which should have forced the lateral scrolls to catch on the pupil margins. When they failed to catch on the first attempt (Figure 2), I used a second instrument to push one scroll over the pupil margin. Once three of the four scrolls were hooked by the pupil margins, the disposable medical device holder was removed from the incision site and I inserted a pusher through the incision to introduce the fourth, subincisional scroll onto the iris (Figure 3).

ADEQUATE WORKING SPACE, EXCELLENT SURGICAL RESULTS

The pusher to engage the subincisional scroll should be smaller than the annulus diameter of the scroll. Otherwise, if it fills the whole scroll, the pupil can block the pusher from coming into the scroll, which occurred in this case. I recommend the Osher/Malyugin Ring Manipulator (Mal- 0003; MicroSurgical Technology) for these situations, but at the time I did not have access to one. Therefore, I used a second instrument to liberate the pusher from the small scroll. After successfully positioning the four scrolls of the Malyugin Ring, I achieved a working space of 6.25 mm, which matches normal pupil dilation.

We then carried out successful phacoemulsification and IOL implantation with ease in this mature whitish cataract. Removing the Malyugin Ring was easier than expected, first disengaging the subincisional scroll, which is hooked by the disposable medical device for removal. The only thing to watch for in this maneuver is that the lateral scrolls are in the plane of the disposable holder so that they can be removed through the main coaxial incision.

CONCLUSION

The day after surgery, this patient’s pupil was round and normal. After the impressive results of this case, I decided to introduce the 6.25-mm Malyugin Ring into my flowchart for treatment of nondilating pupils. A subsequent case with the Malyugin Ring can be viewed at eyetube. net/?v=danop.

Johan Blanckaert, MD, is the Director of the Eye and Refractive Centre, Ieper, Belgium. Dr. Blanckaert states that he has no financial interest in the products or companies mentioned; however, he is a member of the speaker’s bureau for Alcon Laboratories, Inc., and has conducted research for Novartis, Pfizer, PhysIOL, and Allergan in the past 12 months. He may be reached at tel: +32 57 202300; e-mail: oogartsen@pandora.be