How to fix Iris Prolapse in Cataract Surgery

In this resident performed surgery, we encounter iris prolapse after too much hydro-dissection. This results in the iris prolapsing out of the phaco incision, the anterior chamber shallowing, and the pupil becoming miotic. How do we fix this issue and complete the case?

The key principle is that the iris will tend to prolapse if there is a pressure gradient with high pressure behind the iris and lower pressure in front of the iris. To resolve the iris prolapse, we need to equalize the pressure gradient.

Some surgeons choose to equalize this pressure gradient by injecting viscoelastic on top of the iris. This increases the pressure in front of the iris, to match the high pressure behind the iris. It works, but just temporarily until the viscoelastic is displaced or washed away. A better solution in most cases is to release the high pressure from behind the iris.

In this case, we have trapped balanced salt solution (BSS) behind the iris. Using the cannula or other instrument, we can depress the prolapsed iris and the floor of the main incision to release this fluid. Then, once the pressure gradient is gone and there is low pressure both in front of and behind the iris, the prolapse resolves and the iris stroma goes back into position.

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