Medical and surgical management of the small pupil during cataract surgery

Abstract

As cataract surgery continues to evolve, the intraoperative small pupil continues to pose challenges to even the most experienced cataract surgeon. Several steps can be taken preoperatively to decrease the chance of intraoperative miosis. Even so, the problem of miosis during cataract surgery remains a relatively common occurrence. This paper discusses many steps, both preoperative and intraoperative, that can make surgery technically easier and safer, thus maximizing the postoperative outcomes and patient satisfaction. Complications associated with small-pupil cataract surgery, risk factors for intraoperative miosis, the preoperative and intraoperative management of the small pupil during cataract surgery, and postoperative care are reviewed.

Efficacy of a hinged pupil expansion device in small pupil cataract surgery

“…systemic alpha-adrenergic antagonists, pilocarpine, or carbachol). [ 29 ] The patient population in the present study includes a wide sampling of these risk factors.…”

Cataract in the Adult Eye Preferred Practice Pattern®

“…1041 Mechanical methods include viscomydriasis, release of posterior synechiae, pupil stretching, mini sphincterotomies, iris retractors, and pupil expansion rings. 1042,1043 Patients should be offered surgical repair of symptomatic iris defects caused by cataract surgery. 1044 Intraoperative floppy iris syndrome is a unique small-pupil syndrome associated with iris billowing and prolapse as well as with progressive intraoperative miosis.…”

Evaluation of femtosecond laser-assisted anterior capsulotomy in the presence of ophthalmic viscoelastic devices (OVDs)

“…In cataract surgery, either in FLACS or conventional phacoemulsification, a small pupil makes the surgery more difficult, due to the reduced visibility of the anterior lens capsule, lack of red reflex and limited space for intraoperative manipulation 4 , 9 . It also increases the intraoperative risk of iris trauma, retained lens matter and posterior capsule rupture 9 . Poor pupil dilation may be found in patients with diabetes, pseudoexfoliation, senile atonic pupils, posterior synechiae, long-term pilocarpine usage and trauma 4 , 9 .…”

“…It also increases the intraoperative risk of iris trauma, retained lens matter and posterior capsule rupture 9 . Poor pupil dilation may be found in patients with diabetes, pseudoexfoliation, senile atonic pupils, posterior synechiae, long-term pilocarpine usage and trauma 4 , 9 . A limitation of all current FSL platforms is the prerequisite for patients to have adequately dilated pupils 2 .…”

“…Malyugin ring, iris hooks, etc. ), to enable adequate pupillary dilation for femtosecond anterior capsulotomy 9 – 12 . A 3-step sequential approach has been suggested, with the use of intracameral epinephrine (0.1% solution), viscomydriasis and subsequent mechanical pupil expansion, if needed 12 .…”