Surgery: Malyugin Ring for Intraoperative Floppy Iris Syndrome

Dr. Dasa V. Gangadhar: In patients with small pupils, especially those on medications known to cause intraoperative floppy iris syndrome, IFIS, pupil expansion devices can be lifesavers. I will present just a few pearls on insertion and removal techniques of the Malyugin ring. Although this is my device of choice, please note that there are other pupil expansion devices on the market.

I present a case of a 75-year-old patient on tamsulosin. The behavior of his other eye has already taught me the very floppy nature of his iris. Hence, I decided to place a Malyugin ring. When placing the ring, always capture the distal iris with the scroll of the ring, as you can see here. Then as the ring is further inserted, gently tilt the device, allowing iris capture with the medial and lateral scrolls of the ring. As three facets of the ring are already nicely in place, the proximal aspect of the ring can easily be manipulated into place.
I have used various hooks, including a Lester and Kuglen, but have found the Malyugin manipulator allows for the easiest grasp of the ring. Once the intraocular lens has been inserted and centered, as we are doing here, the distal scroll of the Malyugin ring can easily be disinserted.

The Malyugin manipulator is now reintroduced into the eye. The proximal scroll is easily grasped and disinserted from the iris. The inserter device is then placed into the eye, the proximal scroll is ensnared, allowing for seamless removal with minimal iris manipulation. I have found this technique to be friendlier to the iris then simply grasping and removing the ring from the eye.

In summary, pupil expansion devices have made IFIS cases rather routine in the majority of surgeries.