If you think you need it, use it!

Surgical adjuncts are not commonly used during routine cataract procedures. However, if complexity exists or complications occur intraoperatively, they can become a surgeon’s best friend. The need for these specialized tools and instruments should always be considered as part of surgical pre-planning to simplify the case and increase safety through avoiding complications. So why are we so reluctant to use them?

In this part of the Complex Cases, Simplified series, Dr. David Lockington addresses the attitudes toward adjuncts and makes a compelling case for the use of the Malyugin Ring 2.0. To get more details on the cases Dr. Lockington describes, we invite you to watch the accompanying webinar recording (click on the link below).

David Lockington, MB BCh BAO(Hons) FRCOphth PhD. Consultant Ophthalmologist, Tennent Institute of Ophthalmology, Glasgow, Scotland; Honorary Clinical Senior Lecturer, University of Auckland, New Zealand.

Do No Harm — Could or should?

Patients often ask their surgeons “What can you do for me?”. I respond to this question carefully. Surgeons know that harm can occur during any procedure, so discussing the risks and benefits of “What should I do?” with the patient is the essence of informed consent. The best surgeons don’t just think about how to operate, they also consider when not to operate. Moreover, he or she takes precautions to reduce the chances of harm through surgical planning and ensuring the availability of surgical adjuncts.

Surgical adjuncts are an essential part of the safety narrative in ocular surgery. I always advocate for the principle “if you think of it, use it”, but it is better to have planned to use such a device in advance. There are different barriers to employing adjuncts, which can be grouped into two categories: (1) managerial attitudes (e.g., “Adjuncts are expensive.”), and (2) clinical attitudes (e.g., “I don’t really need to use this tool.”).

How Much Does a Complication Cost?

When discussing the use of adjuncts, it is vital to consider the true costs of not using them, including costs of clinical follow-ups when a surgical complication occurs, as well as practical consequences for the patient. Our recent publication in the journal Eye provides good evidence to support the early use of surgical adjuncts in cataract surgery from a cost-saving perspective [1]. The detailed cost analysis demonstrated that the “cautious” approach with adjuncts (1.4% sodium hyaluronate, iris expansion ring, trypan blue capsular stain) compared favorably to the “minimalist” approach without using adjuncts which then led to complications. In fact, it could be more than nine times more expensive not to use early adjuncts; for example, if there was a surgical complication that required secondary procedures.

Even in a less complicated scenario, the difference would still be significant. We demonstrated that as soon as you need to open the AntVitKit Anterior Vitrectomy Kit (i.e., there is a complication involving vitreous loss), the initial cost-saving of not using initial adjuncts evaporates.

Using the Malyugin Ring 2.0 to Avoid Complications in IFIS

The Malyugin Ring 2.0 (MicroSurgical Technology Inc., Redmond, Washington, USA) is a surgical adjunct I often use in my practice. It comes in two sizes, 6.25mm and 7.0mm. This microtool has many advantages that make it a great choice for the safe management of small pupil and intraoperative floppy iris syndrome (IFIS).

Malyugin Ring 2.0 illustration.

When we see a patient in the clinic, the iris can look normal. Taking a proper history may warn us regarding previous use of alpha-blocker medications. However, during the surgery, the situation can deteriorate, so we need to be prepared. If we ignore the warning signs and persevere with the only plan we have, complexity may result in complications.

As I discussed in the webinar, there are different approaches we can take with IFIS. A bimanual approach should reduce iris mobility compared to a coaxial system, as the irrigation remains above the iris. Intracameral phenylephrine has been successfully used as a pharmacological method to address IFIS as well, as long as the dosage is accurate [2].

The use of the Malyugin Ring, however, seems to be the definitive solution for stabilizing the iris. Its’ flexible material simplifies insertion and removal. It also provides enhanced intraoperative visibility and maneuverability. I have a few tips on how to best use the device which I shared in the video, including how to guide the scrolls in and use the handshake technique.

Impact of Malyugin Ring on Buckling in IFIS

My team has also been researching iris movements. We have previously published a model of abnormal iris movements and have refined it recently to look at the impact of pupil size, floppy iris parameters, and mechanical ring devices [3].

We found that if you use the 7mm mechanical expansion device to pin the iris, this increases the initiating buckling pressures significantly and restricts the iris movement.

This explains why the Malyugin Ring 2.0 is so effective in floppy iris syndrome as it helps to stabilize the iris movement and inhibit iris buckling. This mechanical restriction means the iris cannot move centrally to touch the instruments, or peripherally to prolapse out the wounds.


Adopting the “cautious” approach with early adjunct use to address the complexity and avoid complications makes sense from a cost-effective perspective. But, above all, it serves our patients. Learn how to use adjuncts safely; for example, by practicing on simulators and models that are now readily available for tools such as the Malyugin Ring. Know what to do, before you do it!

Key learnings

  • Adopt a safety-first mentality for your patients.
  • Prevention of cataract surgery complications is more cost-effective than the management and follow up of complications.
  • Every low-risk case can become complicated if we do not plan. In contrast, every high-risk case can be simplified by appropriate and timely adjunct use.
  • The Malyugin Ring 2.0 is a very useful adjunct for a safe management of small pupils and IFIS as it helps to inhibit iris billowing.

Watch the webinar recording on the link below.

MST’s philosophy statement is “We make great products that people love”, which guides us in the way we choose and design our products.