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October 2009



Lens-Iris Diaphragm Retropulsion Syndrome 

Joel K. Shugar, MD, sadly passed away last year. His “shugarcaine” solution has proved to be quite helpful with intraoperative floppy iris syndrome (IFIS) patients, as was mentioned in “Managing Intraoperative Floppy Iris Syndrome” (Pearls, May).

I have found that it also can be helpful in cataract surgery in the high myope—a procedure that causes concern for most ophthalmologists. Even if the surgeon goes into the eye with a low bottle height, the anterior chamber can deepen, stretching the pupil and zonules and causing the patient pain (lens-iris diaphragm retropulsion syndrome). This reverse pupillary block often breaks, the anterior chamber shallows and the pupil constricts, complicating the case.

While a few solutions have been offered, usually lifting the pupillary margin to prevent the reverse block, I have found that a modified Shugar solution—eliminating lidocaine and using 0.2 cc of preservative-free and sulfite-free epinephrine with 0.6 cc of BSS—works perfectly. I have now used it on five patients at various stages of cataract removal to stabilize the iris and anterior chamber.

One patient had an expansion of the anterior chamber in her first eye at the time of surgery with subsequent loss of dilation. So, on her second eye, I instilled the IFIS solution before starting the capsulorhexis. It proceeded like any normal case despite this patient’s high myopia.

In another instance, the case started off poorly, with deepening of the anterior chamber, widening of the pupil and increasing pain for the patient. About halfway through the phaco, the iris separated from the lens capsule and the chamber quickly shallowed, with a loss of dilation. Normally, I would have put iris hooks in, but I decided instead to instill 0.3 cc of the IFIS solution above the iris. The pupil immediately dilated and the iris became taut, lifting off the capsule. Going back to finish the phaco caused no movement of the iris or pupil.

Lawrence J. Geisse, MD
Los Alamitos, Calif.


IOL Satisfaction Test 

We were interested to see the article “Working to Make the Premium IOL Patient Happy” (Feature, February). Our group is currently developing a measure to predict patient satisfaction across a wide range of medical procedures. We hope that our work will result in a test that will assist ophthalmologists in better selection of candidates for procedures such as LASIK and premium IOLs.

The Berger-Owens Surgical Screen-Version I (BOSS-I), presented at the 2008 annual meeting of the American Society for Cataract and Refractive Surgery, was a 36-item measure that could be administered in less than 10 minutes and that correctly predicted whether a patient was likely to become litigious.

The instrument currently in development, the BOSS-II, seeks to expand the success of the BOSS-I and to create a robust predictor of overall surgical satisfaction. We invite any practices interested in contributing data to this study to contact us at

Steven Thomas Berger, MD
Andrew L. Berger, PhD
Shane Gregory Owens, PhD
Commack, N.Y.


What’s the Real Issue? 

The feature “Ethics, Physicians and Industry” (May) presents some interesting ideas on the relationships between physicians and the medical industry. While considerable lip service has been paid to this issue, the Academy, the AMA and patient advocates continue to fail everyone—ophthalmologists and patients—alike. While having lunch with a pharmaceutical representative to discuss a drug can influence some, does this really compare to the most egregious ethics violation—optometric comanagement or pay-for-referrals?

Federal legislators blindly say they can help cure the health care industry by getting rid of prescription pads. Shame on them for not knowing better. But shame on us for allowing the Academy to continue to condone what is the most morally reprehensible act taken out on patients every day. If we can spend this much time discussing the influence of giving away pens and paperweights, shouldn’t we at least finally force the Academy to address a real patient care issue like payfor-referrals?

James V. Martuccio, MD
Warren, Ohio