Modified stretch technique for small pupil phacoemulsification with topical anesthesia

Abstract

I present an atraumatic technique for small pupil phacoemulsification using topical anesthesia. Fifty consecutive small pupil phacoemulsification cases were performed with topical anesthesia and mild intravenous sedation. Viscoelastic combined with a modified two instrument stretch was used for pupillary enlargement adequate for phacoemulsification. After preoperative cycloplegia, two or more multidirectional stretches were used for 3.0 to 5.0 mm pupils; three or more multidirectional stretches were used for pupils less than 3.0 mm. Pain and proprioceptive responses were avoided by reducing the stretch length, leaving the angle structures and ciliary body untouched. Sodium hyaluronate (Healon GV) created additional expansive power. Of 50 successfully implanted cases, 45 (90%) had acceptable pupillary form and function postoperatively. The 5 (10%) with enlarged, atonic pupils had past injury or inflammatory disease. This technique minimizes anterior segment trauma, instrumentation, and operating time.

Intraoperative floppy iris syndrome associated with tamsulosin

“…Mechanical stretching of the pupil is usually effective for small pupils caused by prior miotic use, pseudoexfoliation, or posterior synechia and is a commonly used method to expand the pupil diameter intraoperatively. [1][2][3][4][5][6][7][8]14 This maneuver creates microscopic sphincter tears and does not produce floppy iris behavior in these eyes. 14 However, this technique is usually ineffective in IFIS because the iris pupil margin remains elastic.…”

Patient pain during stretching of small pupils in phacoemulsification performed using topical anesthesia

“…In 1996, Dinsmore 9 reported a technique to stretch small pupils using multidirectional stretches. He concluded in his study of 50 cases performed using topical anesthesia that patients tolerated the procedure well and reported no pain or unusual discomfort during the stretching maneuvers.…”

Combined Cataract and Glaucoma Surgery

“…Injecting a high-viscosity viscoelastic agent aids in assessing the extent of pupil dilation (Obstbaum, 2000). If the amount of pupil dilation is not adequate, the pupil is stretched either using two instruments, such as Kuglen hooks (Dinsmore, 1996). The surgeon introduces one Kuglen iris hook through the tunnel incision or a paracenthesis incision and a second Kuglen hook through a paracentehesis incision.…”