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Innovation at heart of scientific advances, but surgeons must remember their duty and responsibility to share knowledge

Dermot McGrath

Posted: Monday, October 9, 2017

Boris Malyugin, who presented the Binkhorst Medal Lecture ,with ESCRS President David Spalton

Innovation lies at the heart of all scientific advances, but surgeons must always remember their duty and responsibility to share their knowledge for the benefit not just of their peers but more importantly their patients. So said Boris Malyugin MD, PhD, in his Binkhorst Medal Lecture delivered as part of the opening ceremony of the XXXV Congress of the ESCRS.

“At the heart of almost each and every innovation that drives us forward, there are inherent drawbacks and unsolved problems. Striving to overcome these hurdles is what drives further innovation,” said Dr Malyugin. “As surgeons, we have to innovate and share in order to bring our best to the patient. As the baseball legend Jackie Robinson put it: ‘A life is not important except in the impact it has on other lives.’”

In a wide-ranging lecture that focused on the challenge of cataract surgery in high-risk eyes, Dr Malyugin, Professor of Ophthalmology and Deputy Director General at the S. Fyodorov Eye Microsurgery Federal State Institution in Moscow, Russia, paid tribute to predecessors such as Cornelius Binkhorst, whose work was instrumental in the development of intraocular lenses, and Svyatoslav Fyodorov, who designed the “Sputnik” pupil-fixated IOL.

Turning to the question of high-risk eyes in cataract surgery, Dr Malyugin said that small pupils pose a significant challenge even for skilled and experienced surgeons, and should not be taken lightly.

“Poor mydriasis is not purely a geometrical issue – it is a lot more complex than that. A small pupil is an indicator of underlying pathologies within the eye, and is usually associated with systemic or local comorbidities, including but not limited to zonular pathology, blood-aqueous barrier disruption, pseudoexfoliation syndrome and intraocular pressure spikes,” he said.

Small pupils are also associated with an increased risk of complications such as iris trauma, capsular rupture, vitreous loss, inflammation, incomplete evacuation of the cortical material and difficulties with placing and aligning the IOL in the bag, he added.

While the ESCRS landmark study on the use of intracameral antibiotics for endophthalmitis prophylaxis has encouraged greater use of intracameral mydriatic agents in cataract surgery, this pharmacological approach does not work all the time, said Dr Malyugin.

If the intracameral injection does not provide sufficient mydriasis, one strategy is to proceed with viscodilation, posterior synechiolysis and pupil-stretching techniques, if appropriate, said Dr Malyugin.

Dissecting posterior synechiae will invariably improve mydriasis, and surgeons may also consider using mechanical expansion devices such as iris hooks or pupil rings.

Early in his surgical career, it was the frustration of working with first-generation pupil-expansion rings that prompted Dr Malyugin to try to improve on those initial designs.

“These early expansion rings were not easy to work with and they could lead to complications with the surgery,” he said.

This provided the initial inspiration for the Malyugin Ring, a pupil expansion ring that would be easier to inject and position within the eye and that could be implanted with minimal trauma and removed through micro-incision.

It can be inserted through regular incisions as well as through the 1.6-1.8mm microincisions used in MICS, with a wound-assisted technique of insertion and removal, he said.

These advantages and solid clinical results from the first trials of the device spurred phenomenal demand for the Malyugin Ring, with more than one million of the devices used in cataract patients since its introduction a decade ago.