Lessons learned

illustration: Dr Soosan Jacob I am very grateful to the ESCRS for the honour of being invited to deliver the Binkhorst Medal Lecture. It is really a true privilege to be able to share some knowledge and experience in ophthalmic surgery which I have acquired over the years of my clinical practice.  . It is really a true privilege to be able to share some knowledge and experience in ophthalmic surgery which I have acquired over the years of my clinical practice. In our careers as surgeons we can help thousands and sometimes tens of thousands of patients. But if you share your knowledge it can multiply the number of people being helped even further.The message I am hoping to convey in my lecture is that we definitely need to try to innovate, learn and teach. It's good to have the knowledge, but it is better to also share it because we never stop learning. I also think we can take some inspiration from Cornelius Binkhorst, who was a pioneer in intraocular lenses (IOLs), suggesting the new principle of pupil fixation. He and my mentor Svyatoslav Fyodorov knew each other well. Actually, Prof Fyodorov further developed the ideas of Binkhorst, designing the pupil-fixated IOL called ‘Sputnik’ which was very popular at a certain point in time, not only in Russia but internationally. I was in training and I am still working in an institution that bears Prof Fyodorov’s name today. It comprises a system of clinics throughout Russia employing about 5,000 people, including over 1,000 doctors. We also have manufacturing facilities for designing and producing surgical instruments. This combination allows the combination of a high level 
of practice with extensive educational activities and scientific research. THE PROBLEM OF SMALL PUPILS The main focus of my lecture will be dealing with the problems associated with small pupils in eyes undergoing cataract surgery.http://www.eurotimes.org/small-pupils/ This is quite a complex problem and it is not a purely geometrical issue. A small pupil is an indicator of underlying pathologies within the eye, and is usually associated with systemic or local comorbidities including pseudoexfoliative syndrome and glaucoma. Small pupils can also result from trauma, inflammation, uveitis and so forth. Therefore, the surgeon is dealing with eyes having a variety of different clinical conditions. That, in turn, brings an increased risk of not only intraoperative but also postoperative complications, such as bleeding and inflammation. Recent advances have improved the situation for small pupils in eyes undergoing cataract surgery. Thanks to the work of the ESCRS on intracameral antibiotics for endophthalmitis prophylaxis led by the late Peter Barry, we are now moving more towards the use of intracameral medications in our procedures. Intracameral mydriatic agents help with enlarging the pupil and sustaining it at a large diameter throughout the surgery. That is the pharmacological approach. However, it does not work all the time. Thus, the other path is surgical. Dissecting synechiae and cutting through fibrotic tissue with scissors or other types of cutting instruments release the pupil and allow it expand.One can also consider using mechanical expansion devices such as iris hooks or pupil rings. Although pupil expansion rings were already available when I first started in ophthalmology, they were not so comfortable or easy to work with and they sometimes caused complications. I therefore worked on creating a new design of pupil expansion ring, the Malyugin Ring, that is easier to inject and position within the eye than the earlier expansion rings and can be gently implanted and removed through micro-incision. My innovations have provided a platform for further innovations with new capabilities. Different groups all over the world try to replicate the huge success of the Malyugin Ring and create newer ring designs. However, we are not standing still with the Malyugin Ring either, and now the second generation of the device (Malyugin Ring 2.0) is available, which is softer, gentler to the iris, and easier to implant and remove.Over the years we have learned that the newest technology that is having distinct advantages might in turn have some drawbacks. Femtosecond laser-assisted cataract surgery (FLACS) is a good example of that. It has the advantage of high precision in the creation of incisions and capsulorhexes, and lens fragmentation, however as a result of prostaglandins released in response to the laser, in a certain number of cases there is pupil size reduction, necessitating the use of the pupil expansion devices.I consider that a philosophical issue. In the core of almost each and every innovation that drives us forward there are inherent drawbacks and unsolved problems. That in turn becomes the basis for the new innovation spiral. As medical doctors, as surgeons, we have to innovate and share in order to bring our best to the patient. Boris Malyugin MD, PhD is Deputy Director General (R&D, Edu) at the S. Fyodorov Eye Microsurgery State Institution in Moscow, Russia • Interview by Roibeard Ó hÉineacháin

Tags: Boris-Malyugin, cataract and refractive, small pupils