The iris hooks are removed after the implantation of the intraocular lens (IOL). For removal, the anterior chamber should be filled with OVD. The iris hook is first pushed inside to disengage the pupil. then it is drawn outwards. In cases with zonular instability and small pupil, the side coils of the ring may be used to hold both the iris margin and the capsulorrhexis edge. Thus, a single device is used for both pupillary dilation and stabilization of the capsular bag [14]

The current version is called Malyugin ring 2.0 can be inserted through a 2 mm incision using a modified injector. Other modifications from the previous model include thinner material (5-0 polypropylene), wider coil gap, and more soft and elastic material. This model was released in 2016. Because of the thin profile, chances of damage to delicate ocular structures may be less. Also, the device typically does not hinder the surgical maneuvers, and inadvertent disengagement from the iris during surgery is very rare. Insertion and removal of this ring may be easier and faster than other options. [9] Two sizes are available 7 mm and 6.25 mm. It is similar to the phaco-incision Brown pupillary dilator. The pupillary margin is caught at 2 places 180° apart, and then the 2 catches are separated maximally to dilate the pupil. Wirbelauer C, Schmidt S, Puk C. Mechanische Pupillenerweiterung mit Ringen zur Kataraktoperation bei enger Pupille: Videobeitrag [Mechanical pupillary dilatation using rings in small pupils during cataract surgery: Video article]. Ophthalmologe. 2018;115(4):329‐335. doi:10.1007/s00347-018-0678-0 The JT-RS151P is perfect for an accurate and easy stretching of all kinds of rings, including some types of stones. Before you stretch your ring, please make sure that you anneal it in advance to avoid unnecessary destruction. Push the lever until there’s some resistance. When you feel resistance, this is when you should be careful. Apply less pressure at this point. Tan RKY, Wang X, Perera SA, Girard MJA. Numerical stress analysis of the iris tissue induced by pupil expansion: Comparison of commercial devices. PLoS One. 2018;13(3):e0194141. Published 2018 Mar 14. doi:10.1371/journal.pone.0194141

Yuguchi T, Oshika T, Sawaguchi S, Kaiya T. Pupillary functions after cataract surgery using flexible iris retractor in patients with small pupil. Jpn J Ophthalmol. 1999;43(1):20‐24. doi:10.1016/s0021-5155(98)00055-0 Agarwal's modification- A suture is passed through the leading coil so that the device can be retrieved in cases with suspected posterior capsular rupture. [11] Agarwal A, Malyugin B, Kumar DA, Jacob S, Agarwal A, Laks L. Modified Malyugin ring iris expansion technique in small-pupil cataract surgery with posterior capsule defect. J Cataract Refract Surg. 2008;34(5):724‐726. doi:10.1016/j.jcrs.2008.01.024 Initial results of Bhattacharjee ring in 42 eyes showed that there was adequate dilation, no incidence of spontaneous device engagement, intraoperative hyphema in 2 eyes, iridodialysis in one eye, postoperative round pupils in all but 2 eyes, microscopic sphincter tear in 10 eyes, and iris chafing in 6 eyes. [29] Bhattacherjee ring has a very low vertical height of 0.1 mm which may offer an advantage in very shallow anterior chambers.

We’ll show you a couple of oil ring details and how even a mild, normally aspirated street car engine can make more power, spin with less internal friction, and still deliver proper oil control. The tip has a curve to engage the pupillary margin. Both side port and main incision versions are available. Side port version has one c loop facing distally. Two such instruments can be used for pupillary stretching. The main incision (phaco incision) version has 2 C loops facing away from each other and these engage the sub-incisional and distal pupillary margin and the difference between C loops can be increased leading to pupillary dilation. This is described by Dr. John Milverton, of Sydney, Australia. This is a device with a 7 mm internal diameter made from polyurethane. The groove at the outer surface of the device engages the pupillary margin. It may be inserted inside the anterior chamber with a forceps or an injector through the main port which has to be mildly enlarged to accommodate both the phaco/irrigation aspiration handpiece and the portion of the ring which protrudes outside the phaco wound. The device is first inserted into the anterior chamber which has been filled with OVD. The proximal-most area of the ring is first engaged, then adjacent areas are progressively engaged in the pupillary margin. The protruding portion of the ring helps in the removal of the ring after its use. The pupillary margin may get caught in the device resulting in iris injury, but excellent pupillary dilation is usually achieved.

mydriatic with or without NSAID in the irrigation fluid to maintain the dilation and prevent miosis- adrenaline, Omidria® (Omeros Corp., Washington, USA)-phenylephrine 1% & ketorolac 0.3%. Omidria® has been approved by the FDA (Food and Drug Administration, USA) for use in the irrigating solution during cataract surgery to maintain the pupillary dilation (which has been already achieved) by preventing miosis and to prevent pain after surgery. The piston ring gaps should be evenly distributed around the circumference of the piston, staggered at intervals of approximately 120°. Rauen M, Oetting T. Partial retraction of Malyugin pupil expansion device to improve safety during ring removal. J Cataract Refract Surg. 2010;36(3):522‐523. doi:10.1016/j.jcrs.2009.10.034 Reusable polypropylene iris hooks (4-0) are also available. The ability to reuse reduces the cost further.

Chang DF, Braga-Mele R, Mamalis N, et al. ASCRS White Paper: clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2008;34(12):2153‐2162. doi:10.1016/j.jcrs.2008.08.031 Bhattacharjee S. B-HEX pupil expander: Pupil expansion redefined. Indian J Ophthalmol. 2017;65(12):1407‐1410. DOI:10.4103/ijo.IJO_673_17 The Number of Splines: Some stretchers use splines to adjust your ring’s size. Splines are the loose segments on the stretcher’s mandrel that move apart upon pushing up the stretcher’s handle. More splines imply that you can customize more ring sizes, leave alone, giving you room to customize one size more perfectly. Eight splines are better than six, so be sure to go with a larger number of the splines.SOMEBODY Please Tell me how it's really done and help me with those Green/Red colors-they gotta mean something! Tripathy K, Sharma YR, Chawla R, Basu K, Vohra R, Venkatesh P. Triads in Ophthalmology: A Comprehensive Review. Semin Ophthalmol. 2017;32(2):237‐250. doi:10.3109/08820538.2015.1045150 Intraoperative floppy iris syndrome (IFIS) is an important clinical entity which was described in 2005 by Chang and Campbell, This may cause poor pupillary dilation. [1] The iris loses tone and is flaccid in IFIS. IFIS is usually associated with the use of oral Tamsulosin (alpha-1A antagonist), a drug used for benign prostatic hypertrophy. Multiple other drugs can also cause a similar problem. IFIS is characterized by a triad [2] [3] of