From the Guidelines
Iris prolapse during cataract surgery should be managed promptly with immediate wound closure using a cohesive viscoelastic device to prevent further complications, as supported by the most recent evidence from 2022 1. When iris prolapse occurs, the surgeon should first identify the cause, which may include inadequate wound construction, high posterior pressure, or shallow anterior chamber. Management begins with immediate wound closure using a cohesive viscoelastic device to gently reposition the iris back into the anterior chamber. If simple repositioning fails, the surgeon may need to enlarge the wound slightly to facilitate iris replacement without causing tissue damage. Pharmacologic agents like intracameral phenylephrine (1.5%) or epinephrine (1:1000) can help constrict the iris and maintain pupil dilation. In cases of severe prolapse, iris hooks or pupil expansion devices may be necessary to stabilize the iris. After repositioning, the wound should be carefully secured with sutures to prevent recurrence. Postoperatively, topical steroids (prednisolone acetate 1% four times daily) and NSAIDs (ketorolac 0.5% four times daily) should be prescribed to reduce inflammation, along with close monitoring for signs of iritis or iris defects. Prevention strategies include creating properly sized and constructed incisions, maintaining adequate viscoelastic in the anterior chamber, and using iris hooks prophylactically in high-risk cases such as floppy iris syndrome or small pupils. Some key considerations during surgery to minimize complications include the use of viscosurgical devices, minimizing surgical duration and light exposure, and avoiding large corneal incisions and aspirating speculums, as recommended in a recent consensus report from 2024 1.
Key Points to Consider
- Immediate wound closure with a cohesive viscoelastic device is crucial in managing iris prolapse
- Identifying the cause of iris prolapse, such as inadequate wound construction or high posterior pressure, is essential for proper management
- Pharmacologic agents like intracameral phenylephrine or epinephrine can help constrict the iris and maintain pupil dilation
- Prevention strategies, including properly sized and constructed incisions and maintaining adequate viscoelastic in the anterior chamber, can help minimize the risk of iris prolapse
- Postoperative care, including topical steroids and NSAIDs, is important for reducing inflammation and monitoring for signs of iritis or iris defects.
Prevention and Management
The use of viscosurgical devices is recommended to minimize complications during cataract surgery, as stated in a recent report from 2024 1. Minimizing surgical duration and light exposure, avoiding large corneal incisions and aspirating speculums, and keeping the thermal energy of the phacoemulsification device low are also important considerations. Periocular administration or intraocular injection of antibiotics and/or steroids immediately before the end of surgery may be beneficial, and a clear corneal approach is recommended where applicable. Adequate sterilization using povidone-iodine solution should be performed to minimize the need for antibiotics. By following these guidelines and recommendations, surgeons can help minimize the risk of iris prolapse and other complications during cataract surgery, ultimately improving patient outcomes and quality of life.
From the Research
Intraoperative Complications: Iris Prolapse
- Iris prolapse is a complication that can occur during cataract surgery, where the iris bulges out of the incision site 2, 3.
- The mechanism of iris prolapse is explained by the Bernoulli principle and its effect on iris position during the movement of fluid within the eye 3.
- Predisposing factors for iris prolapse include iris configuration, anterior chamber depth, and position and architecture of the corneal tunnel 3.
- Strategies for prevention and management of iris prolapse include the use of pharmacological agents, ophthalmic viscosurgical devices, and iris retractors, as well as alteration and adaptation of the surgeon's technique 3.
- Securing the incisions with a radial 10-0 nylon suture is strongly advocated to provide sufficient wound stability against deformation and prevent iris prolapse 2.
- Iris prolapse can occur after both extracapsular cataract extraction and phacoemulsification, but it is less common after phacoemulsification 4.
- Suturing of extended scleral sections is recommended to prevent iris prolapse, especially when inserting large intraocular lenses 4.