Modified technique for management of LIDRS

We were very interested in the series of articles describing various maneuvers to relieve the reverse pupil block in the lens–iris diaphragm retropulsion syndrome (LIDRS).1–3 To relieve LIDRS, it is necessary to separate the posterior surface of the iris from the anterior surface of the anterior capsule. Previous reports describe maneuvers that lift the iris using the tip of the phaco or irrigation and aspiration (I/A) probe, any second instrument, or even iris retractors. We have described a method in which a dispersive ophthalmic viscoelastic device (OVD) is aspirated in at least 1 quadrant and then the iris is lifted off the anterior capsule to release the block.4 However, we observed that a more efficient way of addressing LIDRS is depressing the anterior capsule instead of lifting the iris. We have since modified our technique, using a combination of aspiration of some dispersive OVD overlying the iris and gentle sustained depression of the exposed anterior capsule rim with the tip of the phaco probe in the same region. We prefer this method for the following reasons: (1) In iatrogenically deep anterior chambers in which visualization is usually difficult, it is technically easier for the surgeon to depress the anterior capsule than to lift the iris. (2) The contact between the iris and the anterior capsule is likely to be extensive in the radial meridian and may require more iris manipulation and aspiration of a significant amount of OVD. This may result in accidental aspiration of the iris as the pupil suddenly clamps down after the reverse pupil block is released. (3) Excessive manipulation may result in pigment dispersion, particularly in Asian eyes with densely pigmented irides, and increased postoperative inflammation. We strongly recommend this technique as we have been able to relieve LIDRS successfully in all the cases we have encountered.