Data show it causes less iris distortion.

While pupil expanders are crucial for performing cataract surgery on many patients, inserting and removing them can still cause complications.

Several devices are available to help patients with small pupils, but some “can be unstable or damage the iris,” says Nicoletta Fynn-Thompson, MD, of the Ophthalmic Consultants of Boston. A new expander from Beaver-Visitec, though, has been shown in a small study to reduce iris distortion, and some ophthalmologists find it easier to use.

The single-use, polyurethane I-Ring, which offers a 7.0-mm field of view, was one of two expanders used in a case study published last year in the Journal of Cataract & Refractive Surgery. I-Ring resulted in 11% distortion, and the other expander resulted in 49% distortion.

Dr. Fynn-Thompson has not experienced any adverse effects or complications while using the I-Ring. “It is quite the opposite. While the iris can occasionally billow, especially in patients who may have intraoperative floppy iris syndrome, the ring remains in place, even with the iris billowing all around it,” she says.

Also, Dr. Fynn-Thompson has not seen sphincter tears, iris pigment shedding or iris atrophy associated with the I-Ring. “I have found the I-Ring … to be a very safe and gentle device in achieving effective dilation.”

Maria Scott, MD, medical director for Annapolis’ Chesapeake Eye Care and Laser Center, has similar experiences with the I-Ring. Dr. Scott has used the I-Ring for about nine months and has found less iris trauma with the I-Ring than other expanders she has used during cataract procedures.

FLEXIBLE, “ELEGANT”

The I-Ring is “a little more elegant” compared to other expanders, says Dr. Scott.

One reason for its level of sophistication is the I-Ring’s injector. Dr. Scott finds the injector very user-friendly since it can be disengaged after inserting the ring into the anterior chamber, but without the ring needing to contact the iris. The ring can then be moved into position using a Sinskey hook.

Dr. Scott appreciates the I-Ring’s ease of use during the operation. “Anything you can use to make the case less stressful is going to help the surgeon and the patient,” as it reduces the risk of complications.

After using it for two to three cases, she found the I-Ring to be easy to insert and remove. She recently used the I-Ring on a patient with a 2-mm pupil, and it helped make the surgery go smoothly; the surgery was free of any complications, she says. At the patient’s postop exam the next day, Dr. Scott found the patient’s iris to be round and free of distortion.

Dr. Scott also finds the ring to be more pliable than similar devices with a low chance of phaco tips tearing the iris, as the I-Ring’s shape matches the eye’s natural anatomy, she says. The positioning holes resting on top of the I-Ring’s frame, above the iris, instead of directly overlapping the eye, also reduce risk of tearing.

Dr. Fynn-Thompson also was pleased with the I-Ring’s design. “The ring ensures iris safety, keeping the Sinskey hook out of contact with the iris, and the flexible hinges allow for easy insertion and removal,” she says.

She finds the I-Ring’s round shape beneficial. “Once the I-Ring is centered, it can act as a guide for my capsulorhexis creation. I typically go approximately 1 mm inside of the expander to achieve an approximate 5-mm capsulorhexis.”

INJECTION AND EXTRACTION

The I-Ring is sealed in a sterile enclosure, attached to the injector. When ready for use, the expander is retracted inside the injector, removed from the enclosure and introduced into the eye through the primary cataract surgery incision.

A Sinskey hook is then used to guide the I-Ring into position, starting with the most distal of the ring’s four channels. The proximal channel, closest to the clear corneal incision, is then guided into position, followed by the lateral channels on the left and right. Dr. Fynn-Thompson finds that rotating the device clockwise from the incision, by about a one-hour position, creates a smoother path for the other cataract surgery instruments.

The ophthalmologist extracts the I-Ring by using the Sinskey hook to release the hinges in the same order they were attached, and then moving the most proximal hinge past the iris, over the dilated pupil. The injector is then inserted, which retracts the ring.

For reimbursement, says Dr. Scott, I-Ring can be coded as code 66982 like with other pupil expansion devices. The cost of the ring to the surgery center will not be reimbursed, she says. OM

Dr. Fynn-Thompson contributed writing to this article. She has spoken nationally, has been published in multiple journals and has a special interest in corneal dystrophies, corneal infections, complex cataract surgery, intraocular lens repositioning and refractive surgery. Email her at nthompson@eyeboston.com.

Dr. Scott and Dr. Fynn-Thompson report no financial ties to Beaver-Visitec.