Use of APX 100 Device for Expansion of Small Pupil in Cataract Surgery and Management of Intraoperative Floppy-iris Syndrome

In cases of small-pupil cataract surgery and intraoperative floppy iris syndrome (IFIS) the potential of intraoperative complications is substantial. The risk of posterior lens capsule tear, dropped nucleus fragments and vitreous loss increases. There are several surgical methods and commercial products designed to deal with small pupil diameter in ocular surgery. Among these, pupil viscodilation with ophthalmic viscosurgical devices, mechanical dilation of pupil with ocular spatula, radial incisions in pupil's sphincter and iris retractors (iris hooks, Malyugin ring, Perfect Pupil ring), are the most popular. Each method has its advantages and disadvantages. Our group developed an innovative iris retractor device named APX 100. It is a disposable stainless steal sterile device designed for mechanical expansion of pupillary diameter during intraocular surgery. The device was approved by the FDA (510K exempt) for iris retraction in small pupil diameters and in IFIS. It comes in a disposable kit with 2 iris retractors and 2 forceps. The study was designed to help us gain more clinical knowledge about the surgical advantages and safety of APX 100 beyond registration data. Patients designated for standard phacoemulsification cataract extraction with small pupil diameter or with documented IFIS in previous eye will be enrolled to the study. The APX 100 will be used intraoperatively in order to retract the iris and expand the pupil. All other cataract extraction surgical stages will remain unchanged. The study includes five study visits: preoperative examination, cataract extraction surgery, first postoperative day, 1 week postoperatively, 1 month postoperatively. All data regarding the intraoperative use of the device and its effect on ocular tissues and final visual acuity will be documented in the patients' files. The preoperative visit will include a thorough eye examination, visual acuity test, intraocular pressure measurement, subjective refraction, measurements to decide the intraocular lens power, endothelial cell counts, corneal topography and anterior segment photography. The second visit will be the cataract extraction surgery itself during which the APX 100 device will be used. On the first postoperative day visual acuity will be tested, intraocular pressure will be measured, a thorough eye examination will be performed and treatment with topical third-generation fluoroquinolone antibiotics and corticosteroids drops will be initiated. Examination one week postoperatively will be the same as in the previous visit, only the topical treatment regimen will be changed - topical antibiotics will be stopped and the dosage of the corticosteroids drops will be lowered and maintained for additional three weeks. The last study visit, 1 month postoperatively, will include subjective refraction, best corrected visual acuity, a thorough eye examination, intraocular pressure measurement, endothelial cell counts, corneal topography and anterior segment photography.