Jennifer H. Hung, MD
Kristiana D. Neff, MD
Department of Ophthalmology
University of South Carolina, Columbia, SC
The authors have no financial interest in the subject
matter of this e-poster.
Background
 Intraoperative floppy iris syndrome (IFIS) is a recognized
triad composed of:
 1) billowing of a flaccid iris stroma
 2) progressive intraoperative pupil constriction
 3) propensity for iris prolapse.1,2,3
 Strategies to minimize intraoperative complications
associated with IFIS include the Malyugin ring pupil
expansion device
 The Malyugin ring has not been evaluated in the hands of
resident surgeons, even though a small pupil may be the
most common challenging feature in resident
phacoemulsification.4,5
Purpose
 To evaluate the use of the Malyugin pupil
expansion device in patients who underwent
resident-performed phacoemulsification cataract
surgery at one surgical center
 To describe intraoperative and
postoperative complications
encountered during early resident
use
Correct positioning of all eyelets of
Malyugin ring using injector
Methods
 Retrospective chart review of all patients who
underwent phacoemulsification surgery at one surgical
center from August 2009 to August 2010
 Inclusion criteria:
 1) resident-performed phacoemulsification
 2) use of Malyugin ring intraoperatively
 3) complete documentation of intraoperative note and
postoperative ophthalmic examinations.
 Included 43 eyes of 36 male patients
Methods
 Intraoperative problems with the Malyugin ring and
signs of IFIS were noted.
 Postoperative best corrected visual acuity (BCVA),
complications and iris abnormalities
(transillumination defects, iris stromal atrophy or
irregular pupil) were recorded.
 Postoperative BCVA was the best visual acuity
recorded within 90 days of surgery.
Results
Dislocation of one or more
eyelets requiring repositioning
occurred in 2 eyes
One or more eyelets snagged
on the retractable injector
hook during removal in 5 eyes
Results
 Iris incarceration by the
trailing eyelet during
removal occurred in 1 eye.
Of note, the Malyugin
ring was removed using
0.12 forceps, not the
injector, in this case.
Results
 Postoperative sequelae:
 Iris stromal atrophy (3 eyes)
 Transillumination defects (2 eyes)
 Pupillary irregularity (1 eye)
 Cystoid macular edema (1 eye)

Responded to treatment with prednisolone acetate and
diclofenac
 There were no cases of extended or excessive
iridocyclitis or pigment dispersion.
 Postoperative BCVA was 20/30 or better in all eyes
(except for 2 patients with prior retinal pathology)
Discussion of Complications
Intraoperative Complication
Dislocation/slippage of eyelets
Suggested improvements
May occur more commonly with 6.25mm
 Malyugin ring. May require use of 7mm
Malyugin ring
Iris incarceration resulting in hyphema,
Ensure iris is fully disengaged from all 4
 eyelets before withdrawing
iridodialysis , or stromal loss
Snagging of eyelet(s) upon retraction
with injector hook
Assist/guide complete retraction of
Malyugin ring into injector with second

instrument vs partial retraction of
Malyugin ring before removal6
Twisting/contortion of the Malyugin ring Partial re-injection of Malyugin ring into
if snagging of eyelet has occurred with
anterior chamber and assist/guide
 retraction into injector with second
continued retraction
instrument as above
Continued iris prolapse during case
 Ensure good wound architecture
Discussion
 Understanding potential complications of Malyugin
ring use is critical for safe usage
 Postoperative sequelae include transillumination
defects, mild pupillary irregularities and stromal
atrophy
 Due to the learning curve, practicing placement and
removal of the device in a wet-lab setting prior to
initial patient use is recommended for resident
surgeons
Conclusions
 With practice and an understanding of potential
complications, the Malyugin ring is safe and effective
for use by resident surgeons.
 Caution is needed in proper placement and removal of
the ring to ensure good postoperative outcomes and
low complication rates, especially when first gaining
experience with the device.
References
1. Chang DF. Use of Malyugin pupil expansion device for intraoperative floppy-iris
syndrome: results in 30 consecutive cases. J Cataract Refract Surg 2008; 34: 835841.
2. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD,
Packard RB, Packer M. ASCRS White paper: clinical review of intraoperative
floppy-iris syndrome. J Cataract Refract Surg 2008; 34: 2153-2162.
3. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with
tamsulosin. J Cataract Refract Surg 2005; 31: 664-673.
4. Ku TK, Rutar T, Han Y, Porco TC, Naseri A. Resident-performed
phacoemulsification in tamsulosin-treated patients. Arch Ophthalmol 2010;
128(8): 967-972.
5. Rutar T, Porco TC, Naseri A. Risk factors for intraoperative complications in
resident-performed phacoemulsification surgery. Ophthalmology 2009; 116:
431-436.
6. Rauen M, Oetting T. Partial retraction of Malyugin pupil expansion device to
improve safety during ring removal. J Cataract Refract Surg 2010; 36(3): 522523.