Fig. 6.42 The ultimate soft shell capsular dye technique (USSCDT). (a) After filling the AC 90% with viscoadaptives, trypan blue is painted over the anterior capsule, beneath the

OVD. (b) The USSCDT provides extreme clarity for capsulorhexis in mature cataracts. Using Trypan Blue in the USSCDT

can be used. Alternatively, the syringe contents may be transferred to a tuberculin syringe.) The drop of trypan blue is then painted over the capsular surface using the distal “blade” of the hockey stick.

3.BSS should be slowly injected under the viscoadaptive onto the capsular surface, keeping the end of the injection cannula near the incision, using a 10 mL syringe and a 27 gauge hockey stick cannula, similar to the one used for the Vision Blue®. Slow injection will not move the overlying viscoadaptive mass, and will wash out any excess trypan blue. Then, the cannula should be moved distally across the AC, and the injection speed should be increased suddenly to a “pulse,” injected away from the wound, with the cannula aperture positioned on the capsular surface near the remote pupil margin, remote from the incision, in the style of the USST. This will force the viscoadaptive upwards and backwards, toward the incision, to blockade the incision and pressurize the eye. Figure 6.42b illustrates the ensuing capsulorhexis, showing the crystal clear view of the capsule that ensues, greatly facilitating capsulorhexis.

6.4.2.6Flomax® Intraoperative Floppy Iris Syndrome USST

Intraoperative floppy iris syndrome is an even more common problem due to the use of a-A1 antogonists, for benign prostatic hypertrophy, of which tamsulosin (Flomax) seems to be the worst, but it can occur with others and some psychiatric drugs as well. An OVD technique to manage IFIS has been described, which can be

used alone, or in combination with iris hooks, a Malyugin ring, or alone, depending on the severity of the case [16].

The IFIS SST-USST is performed as follows (Fig. 6.43):

1.Preoperative dilation test: To determine in advance, the expected severity of IFIS during surgery, all patients on Flomax undergo a preoperative dilation test, 1 week prior to surgery: they are given Mydriacyl (tropicamide) 1% gtts × 2, 5min apart, and Mydfrin (phenylephrine) 2.5% gtts × 1. After 20min the pupils are measured. If the pupils exceed 6.5mm, and especially if the patient has brown eyes, no particular difficulty is expected in surgery. 0.5mL Intracameral phenylephrine (5mL BSS mixed with 0.3mL (all) of a phenylephrine 10% minim in a 6mL syringe (diluted to 0.57%)) is injected into the AC after intracameral xylocaine, through the side port, and waited for 1min before making the main incision and starting the surgery. IFIS SST-USST is used, but the flow rate is not generally reduced. If the pupils are about 6mm, some difficulty will be encountered and the IFIS SST-USST is used in addition to intracameral phenylephrine, with lowered flow rates. If the pupils are less than 5.5mm, and especially if the patient has blue irides, the intracameral phenylephrine and IFIS SST-USST is used with flow rates in the range of 15mL/min, and a Malyugin ring is added

2.After making a 1mm. side-port with the Arshinoff side-port diamond knife (Diamond Surgical Products, Thornville, OH), and firming up the eye with 1% nonpreserved isotonic lidocaine, the primary clear-corneal phaco incision is fashioned with the