CONTENTS

PART I Preoperative Considerations 20 Advanced Principles of Phacoemulsification

Platforms, 175
1 Pathology and Classification of Cataracts, 3 Jeff Pettey, Barry S. Seibel, Kevin M. Miller, and Sumit (Sam) Garg
Mark D. Bailey and Masih U. Ahmed 21 Extracapsular Cataract Extraction and Manual
2 Preoperative Evaluation and Preparation of the Small-incision Cataract Surgery, 187
Cataract Patient, 11 David F. Chang and Rengaraj Venkatesh
Charles Daniel McGuffey, Nicholas Hackett, Surendra Basti, and 22 Principles of Nuclear Disassembly, 197
Kourtney Houser Thomas A. Oetting
3 Current Concepts in Intraocular Lens Power 23 Phaco Chop Techniques, 203
Calculations, 25 David F. Chang
Seth Michel Pantanelli 24 Tilt and Tumble Supracapsular
4 Intraocular Lens Calculations After Refractive Phacoemulsification, 213
Surgery, 39 Elizabeth A. Davis and Richard L. Lindstrom
Ravi Shah, Li Wang, Douglas D. Koch, and Mitchell P. Weikert 25 Biaxial Microincision Phacoemulsification, 219
Janet M. Lim, Richard S. Hoffman, Annette Chang Sims, and
I. Howard Fine
PART II Intraocular Lenses 26 Femtosecond Laser-Assisted Cataract Surgery, 225
5 Principles of Intraocular Lens Design and Aditya Kanesa-thasan and Kendall E. Donaldson
Biomaterials, 51 27 Cortical Removal, 235
Liliana Werner and Catherine J. Culp Steven H. Dewey
6 Polymethyl Methacrylate Posterior- and Anterior-
Chamber Intraocular Lenses, 63 PART V Astigmatism Management
Jonathan B. Rubenstein and Sarah E. Carballo
7 Posterior Chamber Intraocular Lenses, 69 28 Preoperative Evaluation and Considerations of
Oliver Findl and Stefan Palkovits Astigmatism, 251
8 Toric Intraocular Lenses, 79 Warren E. Hill, Douglas D. Koch, Li Wang, Mitchell P. Weikert, and
Valentijn S.C. Webers and Rudy M.M.A. Nuijts Adi Abulafia
9 Presbyopia-correcting Intraocular Lenses, 87 29 Corneal Incisional Approaches for Reducing
Myriam Böhm, Eva Hemkeppler, and Thomas Kohnen Astigmatism During Cataract Surgery, 259
10 Adjustment of Intraocular Lens Power, 97 Li Wang and Douglas D. Koch
Andrew D. Barfell, Raphael Penatti, and George O. Waring, IV 30 Toric Intraocular Lenses: Selection and Alignment
11 Modular Intraocular Lenses, 101 Methods, 267
Aman Mittal, Douglas D. Koch, and Sumit (Sam) Garg Graham Barrett, Douglas D. Koch, and Li Wang
31 Managing Residual Postoperative Astigmatism, 275
Cassandra C. Brooks, Nandini Venkateswaran, and Terry Kim
PART III Anesthesia and Initial Steps
12 Anesthesia for Cataract Surgery, 109 PART VI Complex Cases
Alexander Knezevic and Sumit (Sam) Garg
13 Ophthalmic Viscosurgical Devices, 115 32 Ultradense Cataract, 283
Priyanka Chhadva and Marjan Farid Patrick W. Commiskey, Amar Krishna Bhat, and Deepinder K. Dhaliwal
14 Antibiotic Prophylaxis and Endophthalmitis, 119 33 Intumescent Cataract, 291
Elizabeth T. Viriya and Francis S. Mah Gabriel B. Figueiredo
15 Inflammation in Cataract surgery, 125 34 Management of Weak Zonules, 299
Yvonne Wang and Sumitra Khandelwal Ehud I. Assia, Guy Kleinmann, and Michael E. Snyder
16 Incision Construction, 133 35 Cataract Surgery in the Small Pupil, 309
Kirsten Wagner and Keith Walter Seng-Ei Ti and Soon-Phaik Chee
17 Capsulotomy, 143 36 Phacoemulsification in the Glaucoma Patient, 321
Vance Thompson Nathan M. Radcliffe and Nicholas E. Tan
18 Hydrodissection and Hydrodelineation, 157 37 Cataract Surgery in Combination With Corneal
Ashvin Agarwal, Priya Narang, and Ashraf Freddie Ahmad Surgery, 333
Joshua C. Teichman
38 Cataract Surgery in Uveitic Patients, 343
PART IV Nuclear Disassembly Sanjay R. Kedhar and Olivia L. Lee
19 Basic Principles of The Phacoemulsifier, 163 39 Retinal Considerations in Cataract Surgery, 353
Kenneth L. Cohen Carl W. Noble, James M. Osher, and Christopher D. Riemann

xvii
xviii Contents

40 Pediatric Cataract Surgery, 363 49 Surgical Instrument Care and Toxic Anterior
Bruna V. Ventura and Marcelo C. Ventura Segment Syndrome, 455
41 Intraocular Lens Exchange and Secondary Phillip Qu and Nick Mamalis
Intraocular Lens Placement, 373
Elaine J. Zhou and Zaina Al-Mohtaseb
42 Traumatic Cataract, 383
PART VIII Postoperative Complications
Mauricio A. Perez Velasquez, Mahshad Darvish, and Michael E. Snyder 50 Corneal Edema After Cataract Surgery, 465
43 Iris Repair and Iris Prosthesis, 393 Cassandra C. Brooks and Preeya K. Gupta
Gregory S.H. Ogawa and Michael E. Snyder 51 Glaucoma After Cataract Surgery, 473
44 Surgery in Short and Eyes, 407 Manjool Shah
Kavitha R. Sivaraman and Michael E. Snyder 52 Retinal Complications of Cataract Surgery, 477
Avni P. Finn and Rahul N. Khurana
53 Subluxated Intraocular Lenses, 487
PART VII Intraoperative Complications Shana Sood and Soosan Jacob
54 Neodymium:Yttrium-Aluminum-Garnet
45 Risk Management in Cataract Surgery, 417 Laser Applications in the Cataract Patient, 499
Bryan S. Lee
Lauren E. Chen, Ken Y. Lin, and Matthew Wade
46 Intraoperative Complications, 423 55 Management of Dysphotopsia, 509
Robert H. Osher, Nicole R. Fram, and David F. Chang
Samuel Masket, Nicole R. Fram, Zsófia Rupnik, Ananya Jalsingh,
47 Vitrectomy for the Anterior Segment Stephen Kwong, and Don Pham
Surgeon, 437 56 Refractive Enhancements After Cataract Surgery, 519
Alexis K. Warren and Keith A. Warren
Kanika Agarwal and Elizabeth Yeu-Lin
48 Issues in Wound Management, 445
Roberto Pineda, Patricia S.O. Kalout, Douglas D. Koch, and Li Wang Index, 523
 35
Cataract Surgery in the Small Pupil
Seng-Ei Ti and Soon-Phaik Chee

CONTENTS
Introduction, 309 Surgical Procedure, 310
Causes, 309 Overview of Intraoperative Small Pupil Enlargement
Uveitis, 309 Techniques, 310
Pseudoexfoliation Syndrome (PXE), 309 Specific Small Pupil Scenarios, 310
Trauma, 310 Phacoemulsification Surgery, 317
Use of Medications: IFIS, 310 Potential Complications, 318
Narrow-Angle Glaucoma, 310 Postoperative Management, 318
Preoperative Management, 310 Summary, 318
Pharmacologic Pupil Expansion, 310 References, 319

KEY POINTS
• The small pupil makes access to the cataract difficult. • Pupil enlargement strategies include the following:
• It is important to establish the cause of the small pupil and to have • Pharmacologic and ophthalmic viscoelastic device (OVD) dilation
a perioperative strategy for patient management to ensure a good • Removal of pupillary membranes and release of synechiae
outcome. • Appropriate use of pupil-expander devices
• The principles involved in managing the small pupil include release • Postoperative management goal is to avoid excessive and prolonged
of adhesions that bind the pupil, widening the pupil, and retaining intraocular inflammation, recurrence of synechiae, or occurrence
the pupil expansion. of cystoid macula edema (CME).

INTRODUCTION UVEITIS
Cataract surgery in the small pupil poses a technical challenge because Uveitic cataracts (e.g. Fuchs’ heterochromic uveitis syndrome, sarcoid-
it obscures visualization during all stages of phacoemulsification and osis, Behcet’s disease, Vogt-Koyanagi- Harada disease, juvenile idio-
therefore surgical access to the cataract is limited. Not infrequently, this pathic arthritis-associated uveitis etc.) account for about 1.2% of all
small surgical field is further exacerbated by the presence of a shallow cataract surgeries1 and may be associated with a poorly dilated pupil.
anterior chamber (AC). The target pupil diameter should exceed 5 mm In recurrent fibrinous or chronic uveitis, posterior synechiae (PS) may
to facilitate the formation of an adequately sized continuous curvilin- be present at the pupil or broadly across the posterior surface of the iris.
ear capsulorrhexis (CCC) for safe cataract surgery. An adequately sized Often, a partial membrane is found at the edge of the pupil. In more
CCC is important to prevent anterior capsular phimosis, especially in severe cases, the membrane may be more extensive, causing seclu-
uveitic eyes. sio or occlusio pupillae. When dealing with these pupils, one would
To overcome the small pupil challenge, the strategy for good surgi- anticipate microbleeding and increased risk for postoperative fibrin
cal outcome includes evaluating the systemic and local factors lead- formation. In addition, these eyes are at increased risk for CME and
ing to poor pupil dilation. Careful surgical planning should include exacerbation of uveitis.
the need for pupil expansion, having the necessary instruments and
devices at hand, and the technique of phacoemulsification.
This chapter focuses on optimal preoperative evaluation, options
PSEUDOEXFOLIATION SYNDROME (PXE)
for minimally invasive pupil management, phacoemulsification tech- PXE is a systemic condition in which there is deposition of white, flaky,
niques in small pupils, and preemptive management of possible intra- elastic fibrillin and basement membrane material within the eye and
operative and postoperative complications. in other organs, such as the heart, lung, liver, and kidneys. In ocular
PXE, fine, white fibrillar deposits on the lens capsule, ciliary body,
zonules, corneal endothelium, iris and pupillary margin, and anterior
CAUSES lens capsule occur and are often associated with a poorly dilating pupil,
A variety of systemic and ocular conditions may predispose individu- reduced endothelial cell count, glaucoma with or without zonular dial-
als to a small pupil. Advancing age and additional associated comor- ysis, and phacodonesis.
bidities such as diabetes mellitus are commonly associated with poorer Stabilization of the glaucoma before cataract surgery is impor-
dilating pupils. Other important conditions are discussed below. tant. Consideration should be given whether lens removal alone or a

309
310 PART VI Complex Cases

combined lens-glaucoma procedure is preferred. Before cataract sur- • Decide on the instruments and devices needed to manage the pupil.
gery, avoiding topical prostaglandin analogs may reduce the risk for • Phacoemulsification is preferred to small-incision manual cataract
postoperative CME. surgery because the smaller phacoincision techniques incur a less
Even when the zonules can be imaged and appear intact, they are inflammatory response.
weak and may give way during surgery, and it is important to be pre- • It may be better to defer implantation of an intraocular lens (IOL) if
pared for this. the uveitis is not well controlled.
• The IOL should preferably be a hydrophobic acrylic IOL, implanted
in the bag and not in the sulcus. Diffractive multifocal IOLs can
TRAUMA be considered, provided that visual potential is normal and if the
Blunt ocular trauma or focal penetrating corneal trauma may be the uveitis is unlikely to affect this visual potential in the foreseeable
underlying cause of an irregular pupil; the pupil may dilate poorly at future.
the area of posterior synechiae and may also be associated with focal or
partial zonular weakness.
PHARMACOLOGIC PUPIL EXPANSION
The usual combination of drugs for perioperative pupil dilation is a
USE OF MEDICATIONS: IFIS cycloplegic mydriatic (tropicamide 1%) and adrenergic receptor ago-
Intraoperative floppy iris syndrome (IFIS)2,3 was first described in nist (phenylephrine 2.5%).7 However, these may have little effect on the
20052 in relation to the systemic administration of an alpha-1a antago- small pupils because of chronic drug therapy or synechiae. Use of topi-
nist, tamsulosin. In recent years, IFIS has also been documented with cal nonsteroidal antiinflammatory drugs (NSAIDs) just before cataract
other systemic alpha-1-antagonists, such as doxazosin and terazosin. surgery is useful to minimize intraoperative miosis.8
The condition arises because of atrophy of the iris dilator muscle and
reduced iris tissue tone, causing irregular iris behavior during sur-
gery. In addition to a poorly dilating pupil, severe IFIS cases exhibit
SURGICAL PROCEDURE
increased risk of iris billowing, risk of prolapse at incisions, and pro- This surgery may ideally be done under regional or intracameral anes-
gressive intraoperative miosis. This may develop as soon as 1 day after thesia (preservative–free lignocaine 2%) as manipulation of the iris can
consuming a single dose of tamsulosin. Discontinuing the medication be painful in spite of topical anesthesia. For patients who are anxious
before surgery does not reverse the risk for IFIS. and are likely to squeeze during the procedure, a regional block is pre-
Other causes of small pupil include chronic use of miotics (e.g. pilo- ferred to avoid iris prolapse. When planning which approach to under-
carpine) for glaucoma and ingestion of narcotics (e.g. codeine, oxyco- take, consideration should be given to whether the iris is stretchable or
done) and of phenothiazines for psychiatric conditions. atrophic and scarred.

NARROW-ANGLE GLAUCOMA
OVERVIEW OF INTRAOPERATIVE SMALL PUPIL
Eyes with short axial lengths (<22.0 mm), shallow ACs, and narrow
angles are often associated with small pupils. Pupil size is progressively
ENLARGEMENT TECHNIQUES
smaller from normal to glaucoma suspect to glaucoma patients.4, 5 The 1. Ophthalmic viscoelastic device (OVD) mydriasis using visco-adap-
reduced pupil size in glaucoma is caused by the disease itself and the tive OVD with sweeping movements of the cannula can help enlarge
influence of IOP-lowering eye drops such as brimonidine. the pupil, separate away adherent tissue, and maintain dilation.
2. Surgical manipulation of iris
• Pupillary membrane removal from the pupil edge ( Videos 35.1
PREOPERATIVE MANAGEMENT and 35.2)
Performing an optical coherence tomography of the macula (OCT • Bimanual iris stretching with 2 Kuglen hooks
macula) and optic disc aids in assessing coexisting macula and optic • Multiple partial sphincterotomies
nerve pathology. In addition, where indicated, an ultrasound biomi- 3. Mechanical pupil dilatation9–15
croscopy (UBM) is helpful in assessing zonular integrity. • Iris retractor hooks
For patients with uveitis, preoperative assessment and planning is • Mechanical dilator devices, e.g. Beehler pupil dilator9, 10
highly important.6 Consider comanaging with a uveitis specialist who • Pupil expansion devices (e.g., Malyugin ring,9–15 Visitec I-Ring9, 14)
can help evaluate the cause of uveitis, assist in management of the
inflammation and getting the eye quiescent.
• Establish that the cataract is the cause of poor vision.
SPECIFIC SMALL PUPIL SCENARIOS
• Determine whether preoperative steroid prophylaxis (eye should be
already quiescent for 3 months or more) is required. Alternatively, 1. Minimal Focal or No Posterior Synechiae
intraoperative intravitreal triamcinolone acetonide or steroid implant a. Pharmacologic and OVD Dilation
(e.g., OZURDEX® 0.7 mg dexamethasone) may be considered. • Add 0.5 mL of 1:1000 adrenaline to 500 mL balanced salt
• The presence of peripheral anterior synechiae (PAS), band keratop- solution (BSS®) irrigation fluid.
athy, glaucoma, and so forth should be noted. Determine whether • Use a small aliquot of this mixture through the paracentesis
these should be addressed at the time of cataract surgery or as a site for pharmacologic pupil dilation.
separate procedure before cataract extraction. • The adrenaline in the BSS® subsequently helps maintain
• Patients on antiplatelet medications and anticoagulants should be of pupil dilation during surgery. Adrenaline is also helpful
advised to discontinue these medications before surgery, balancing especially when bleeding occurs during pupil manipulation.
the risk analysis with systemic health, because iris manipulation • The use of visco-adaptive OVD helps to deepen a shallow AC
may result in uncontrolled bleeding. and widen the pupil. Visco-adaptive OVD creates space and
 CHAPTER 35 Cataract Surgery in the Small Pupil 311

is retained to keep the pupil dilated during phaco when the areas of bleeding. Stretching should immediately be stopped
flow rates are high. if tearing of the iris tissue occurs.
b. Unbinding and Opening the Pupil Without Devices • Avoid stretching if the iris is stiff and not stretchable because
• A blunt OVD cannula may be all that is required to sweep the the sphincter can tear, leading to a permanently dilated pupil.
pupil to release focal PS. In such a situation, multiple 0.5 to 1 mm long sphincteroto-
• A Kuglen hook is an efficient instrument to release posterior mies using an intraocular scissors produces a less traumatic,
synechiae all around and can be used to gently push and pull at controlled opening of the pupil.
the pupil edge to release the iris adhesions to the lens capsule. c. Pupil Dilating and Retaining Devices
• Injecting some OVD under the iris helps to avoid engaging • The choice of pupil dilation technique depends on the following:
and tearing the anterior capsule. ■ The surgeon’s familiarity with the device(s)
• Pupil size may be further enhanced by controlled bimanual ■ Whether the iris is stretchable
stretching of pupil using 2 Kuglen hooks, set 180° apart and ■ The size of the eye and the AC depth in relation to the
repeated at 90° to the original meridian (Fig. 35.1A–D). After device’s dimensions
stretching, additional OVD is injected to maintain the pupil • Inserting a pupil retainer device should be as atraumatic to
size, and this may be adequate for milder cases. There may the iris as possible.
be small sphincter ruptures at the sites of stretch, with focal • Understanding the features of each device is important.

A B

C D
Fig. 35.1 Composite operative microscope views demonstrating pupil expansion by stretching
in an eye with a small pupil and normal iris. (A) Two angled Kuglen hooks are used to engage the
edge of the pupil and simultaneously applying diametrically opposing forces kept in maximal
dilating position for several seconds. (B) This is followed by positioning the hooks in the opposite
meridian, taking care not to breach the anterior capsule. Injecting some ophthalmic viscoelas-
tic device (OVD) to lift the iris off the anterior capsule facilitates this process. (C) The stretching
procedure is then repeated. (D) Dispersive OVD is injected to refill the anterior chamber and
the size of the expanded pupil is examined for adequacy to proceed with capsulorrhexis and
phacoemulsification.
312 PART VI Complex Cases

■ I-Ring pupil expander8, 13 (Beaver -Visitec Inc, USA) (ii) Iris Hooks (Video 35.3 )
of polyurethane material is softer to manipulate, can • Self-retaining iris hooks are a good alternative to Kuglen hook
be more protective of the pupil margin compared with pupil stretching.
Malyugin ring, though has a thicker profile and is there- • They come in a set of four or five devices in each package.
fore more space-occupying. • Advantage: each hook is flexible and slim and can easily and
• In addition to pupil expansion, ring pupil retainers also partially safely be placed in a small eye or shallow AC.
inhibit iris billowing.15 • The technique is recommended for the infrequent user and also
(i) Beehler Pupil Dilator for challenging cases.
• The Beehler pupil dilator (Moria, USA) is an instrument that • The position of each hook can be appropriately chosen and vari-
dilates the pupil but is not a pupil retainer. able tension applied to each hook to adjust the pupil size.
• It can be reused and is thus cost saving. • A useful technique is to place one of the iris hooks in or adjacent
• It consists of a fixed subincisional hook together with either two to the subincisional location (i.e., under the main clear corneal
or three hooks on prongs that can be deployed to engage the incision) (Fig. 35.3A–D) to help keep the iris away from the
pupil margin to expand the pupil evenly. phaco probe or prolapsing into the incision.16
• It can be used after pupil membrane removal (Fig. 35.2A–C). It • If the iris is slightly stiff, a combination of iris hooks with mul-
is easier to use in a deep AC and with a pupil that is not exces- tiple sphincterotomies (Fig. 35.3C,D) can help provide a wider
sively small and the iris should be stretchable. opening of the pupil.

B C
Fig. 35.2 Composite operative microscope views demonstrating pupil expansion by Beehler
pupil dilator in a uveitic eye with a stretchable iris and partial pupillary membrane. (A) The edge
of the narrow ribbon of pupillary membrane is carefully picked off the anterior capsule and
grasped with capsulorrhexis microforceps and stripped off the iris gently. (B) The three engaging
arms of pupil dilator and the larger proximal hook are carefully latched on to the pupil margin
which has been elevated from the anterior capsule by injecting some ophthalmic viscoelastic
device. (C) The device is then deployed by pushing on the plunger resulting in stretching of the
pupil. This is kept in maximum dilated position for a couple of seconds before release, achieving
a well-dilated round pupil.
 CHAPTER 35 Cataract Surgery in the Small Pupil 313

A B

C D
Fig. 35.3 Composite operative microscope views demonstrating pupil expansion by iris hooks
and multiple sphincterotomies in this eye with chronic uveitis and a scarred, nonstretchable
iris. (A) Four snug paracenteses are created in an ophthalmic viscoelastic device-filled eye in
a diamond configuration, ensuring that the blade is pointing in the direction of the pupil. This
photograph shows the subincisional paracentesis being created in a position that is more limbal
and posteriorly directed than the clear corneal incision. (B) The iris hooks are inserted one by one
and retracted gradually to open pupil. A tear in the iris is noted as indicated by the red arrow and
further iris hook retraction is immediately ceased. (C) Pupil expansion is completed using intra-
ocular scissors to create multiple small snips of the sphincter pupillae between the iris hooks.
(D) At this stage, the iris hooks are gradually further retracted, providing adequate widening of
the pupil for safe surgery.

• When making the limbal openings through which to place the ■ Version 2.0 (2016): thinner (5/0 polypropylene), more flex-
iris hooks, making the external entry as posterior as practical ible; the inserter fits a 2.0 mm CCI.
with the blade angled posteriorly while creating the opening will ■ It is available in two sizes: 6.25 mm or 7.0 mm.
make the internal entry site closer to the iris surface and will ■ In eyes with moderately sized pupils and normal iris,
reduce anterior tenting or billowing of the now taut iris plane. Malyugin rings are easy to insert and remove, and save the
(iii) Pupil Expansion Rings surgeon creating additional paracenteses.
• Currently, the most widely used pupil expander device is the Method of Inserting Malyugin Ring (Fig. 35.4A–D; Video 35.1)
Malyugin ring9–15 (MST, Redmond, WA, USA; Figs. 35.4 and • A small amount of OVD is injected under the iris to create
35.5), and provides eight points of fixation. some space to accommodate the ring.
• Malyugin Ring (Video 35.1) comes in two versions. • The device is withdrawn into the inserter.
■ Classic version: thicker 4/0 polypropylene, is stiffer; intro- • The leading scroll is inserted to engage the distal pupil
duced via inserter through a 2.2 mm or larger, clear corneal margin.
incision (CCI).
314 PART VI Complex Cases

A B

C D
Fig. 35.4 Composite operative microscope views demonstrating pupil expansion by insertion of
a pupil expansion device, the Malyugin ring. (A) After filling the eye with ophthalmic viscoelastic
device and injecting some under the pupil to just lift the iris off the anterior capsule, the Malyugin
ring loaded on the inserted is introduced into the anterior chamber and the leading scroll care-
fully deployed to latch onto the distal iris margin. Next, the two side scrolls are manipulated
to engage the iris margins. (B) The Sinskey hook or ring manipulator is introduced from side
port to engage the last scroll as the inserter is removed from the eye. (C) Simultaneously, an
angled Kuglen hook inserted through the main incision is used to retract the subincisional iris.
(D) The final scroll then engages the iris margin readily using bimanual manipulation. This avoids
the inadvertent ramming of the proximal scroll into the anterior chamber angle when trying to
engage the distal scroll in a small pupil.

• The two side scrolls are manipulated to engage the pupil ■ Before the last scroll is fully disengaged from the iris,
margins lateral to the incision, with the help of a Sinskey sometimes it may be necessary to use the Sinskey hook to
hook or ring manipulator from the side port. widen the scroll which sometimes does not readily release
• For the proximal scroll at sub incisional area, a Kuglen hook in a thick pigmented iris and may cause bleeding at the
inserted through the main incision is used to retract the iris root of the iris (less common with version 2 of the rings).
to enable the last scroll to easily engage the iris as (or after) 2. Partial Posterior Synechiae With Peripheral Anterior Synechiae
the ring is released from the inserter. (PAS)
Removal of Malyugin Ring (Fig. 35.5A–C; Video 35.1) • When PAS (Fig. 35.6A–C) are present (i.e., peripheral iris is
• There are several techniques of removal. adherent to the cornea endothelium), the PAS should be released
• The authors’ preference (Fig. 35.5): first, before tackling the posterior synechiae.
■ Use a Sinskey hook through the side port to disengage the • Direct the blunt dispersive OVD cannula into the angle space
proximal, subincisional scroll. (Fig. 35.6A).
■ Latch this proximal, subincisional scroll into the retractor • Gently nudge the iris from the endothelium toward the angle
rod of the inserter and pull back on the actuator to slowly without injecting more OVD (Fig. 35.6B). This avoids using
withdraw the ring into the inserter. an excessive amount of OVD, which is ineffective in releasing
■ As the lateral scrolls come together, the Sinskey (or simi- PAS, which are often chronic. Repeat this manoeuvre until the
lar) hook is used to compress them against the inserter so PAS are completely released and the iris is no longer tented
that they slip easily into the inserter. forward.
 CHAPTER 35 Cataract Surgery in the Small Pupil 315

B C
Fig. 35.5 Composite operative microscope views demonstrating removal of the pupil expan-
sion device (Malyugin Ring) under ophthalmic viscoelastic device. (A) The subincisional scroll
is carefully released using a Sinskey hook and positioned on the inserter, allowing the inserter
retraction hook to engage the scroll while the inserter plunger is in the fully actuated position.
(B) The ring is then withdrawn into the inserter. As the two side scrolls come together, a Sinskey
hook inserted from the side port is used to compress them against the platform of the inserter
to ensure they enter the inserter channel smoothly as the rest of the device is retracted and
removed from the eye. (C) This photograph shows the final appearance of the pupil at the end
of surgery.

• For synechiae which do not open with gentle viscodissection, devices can then be applied as needed. Failure to release these
the midpreipheral iris stroma can be grasped with a microfor- membranes may cause decentration of a ring device because of
ceps and gently pulled centripetally, often releasing PAS. uneven pupil dilation.
• If the iris cannot be gently separated from the cornea, do not • In cases of trauma accompanied by iridodialysis, the iris will
persist and avoid sweeping the cannula circumferentially as this first need to be dissected free to open the pupil and then kept
may cause a descemet’s membrane detachment. retracted by an iris hook during phaco. After IOL implantation,
• Dispersive OVD is injected to provide a tamponade when bleed- the iris hook is removed, and then iridodialysis can then be
ing occurs. If there is excessive bleeding, injecting cohesive OVD repaired.
can help clear the bleeding to allow the procedure to continue. When there are PAS that extend centrally, it may be possible to use
• It is helpful to identify any areas in which a pupillary membrane nontoothed micro graspers to gently separate the iris from the cornea
is present or absent and where the membrane edge is well defined (Fig. 35.6C). Sometimes using microscissors to incise the broad bands
and clearly visible at the pupil margin. The narrow strip of pupil- of iris adherent to scarred Descemet’s membrane followed by repair of
lary membrane should be peeled off by using a 23 g capsulor- iris defect using pupilloplasty sutures is preferable because this is less
rhexis microforceps (Fig. 35.2A)-(e.g., Kawai capsulorrhexis traumatic to the cornea and iris. In addition, these pupilloplasty sutures
forceps, ASICO, LLC) to restore the pupil to a regular round also may sometimes prevent reoccurrence of the PAS. However, such
shape. This will also reduce contractile forces of the membrane, manoeuvres are best left to after IOL implantation to prevent a floppy
which may be limiting dilation. Pupil expanding and retaining iris getting caught in the phaco probe.
316 PART VI Complex Cases

B C
Fig. 35.6 Composite operative microscope views demonstrating the release of peripheral ante-
rior synechiae (PAS), which may be present in a uveitic eye with an adherent pupil. (A) Some
dispersive ophthalmic viscoelastic device (OVD) is injected into the anterior chamber without
pressurizing the eye before directing the cannula into the angles, injecting a little more to check
if the PAS will release. (B) For PAS that are adherent, the OVD cannula is use to gently nudge
the iris from the area of adhesion toward the angle without injecting more OVD. Once the PAS
have been released, some OVD is injected to widen the angle. The manoeuvre is repeated until
the entire area of PAS is completely released. (C) In areas where PAS are particularly adherent
and resistant to release, bridges of iris that adherent iris may be released by using micrograsper
forceps to help distract iris from cornea, taking care to direct the force peripherally to avoid strip-
ping of Descemet’s membrane.

3. Seclusio or Occlusio Pupillae peeling. Care should be taken to only grasp the membrane and not
• As above, identify the strip of pupillary membrane that is bind- the iris itself.
ing the pupil edge and causing adhesion to the anterior capsule. • Examine the membrane under high magnification to identify a
It is important to choose the site to initiate the peeling carefully. membrane edge that can be cleanly lifted. Care must be taken not to
Use a 23 gauge (G) capsulorrhexis microforceps to pick up the breach the anterior capsule during these maneuvers.
membrane edge and tear using a capsulorrhexis maneuver (Fig. • If the pupil remains small and immobile, the entire iris may be plas-
35.7A,B; Video 35.1). Repeated regrasping may be necessary. tered to the anterior lens capsule. Use a Kuglen hook or blunt can-
• One should stop pulling if the membrane does not come easily nula to release mild adhesions
to avoid bleeding at the root of the iris. Some mild oozing at the • In the presence of stubborn adhesions, caused by fibrosis of the posterior
pupil margin is not uncommon, though. It is appropriate here to leaf of the iris to the anterior capsule by tough fibrotic tissue, the pupil
switch to a bimanual membrane peeling, introducing a micro- should be opened only to the extent where it is adequate for the cataract
grasper (23 G Ahmed Micro-graspers, MST, Redmond, WA) to to be safely removed without excessive trauma to the iris. Intraocular
grasp the iris stroma and provide counter traction on the pupil scissors (Fig. 35.7C) coupled with micrograspers are required to excise
margin, so that the iris insertion is not bearing the forces of the this fibrous membrane before the capsule can be accessed.
 CHAPTER 35 Cataract Surgery in the Small Pupil 317

B C
Fig. 35.7 Composite operative microscope views demonstrating the removal of a complete
pupillary membrane (occlusio pupillae). (A) Using a 23 G capsulorrhexis microforceps, the pupil-
lary membrane edge is picked up and torn from the iris using a capsulorrhexis maneuver. (B)
When resistance is encountered, the membrane is picked up from a new edge and the mem-
brane is stripped from the opposite direction. (C) In areas where is adherence fibrotic membrane
to the iris is particularly resistant to removal, intraocular microscissors are used to excise part
of the pupillary membrane as atraumatically as possible. Complete removal of the membrane is
essential for even expansion of the pupil.

SURGICAL PEARLS ON PUPIL PHACOEMULSIFICATION SURGERY

MANAGEMENT • Pay attention to wound construction.
• Visco-adaptive OVD can be used to widen a nonadherent pupil and keep it • The main clear corneal incision entry should be radial, symmetric, and
dilated during phacoemulsification. adequately long (tunnel length symmetry across the width of the inci-
• Avoid overfilling the AC with OVD to prevent iris prolapse. sion). An incision length to width ratio is preferably between 3/5 to 3/4.
• Use a blunt OVD cannula or Kuglen hook to release mild posterior synechaie. • A short incision increases the risk for iris prolapse.
• When using iris hooks, aim the paracentesis toward the pupil edge to pre- • Iris retractor and sideport paracenteses need to be snug.
vent it lifting the iris when retracted. • Phacoemulsification technique (Video 35.2): A vertical phaco-
• An iris hook positioned in the subincisional location retracts the iris and chop technique is a safe technique to use as the instruments and all
keeps it out of the way of the phaco probe. maneuvers are kept in the center of the pupil, minimizing risk for
• Iris hooks are preferred when the iris is not stretchable, the AC is shallow, inadvertent iris damage.
and the eye is small. • Cortex removal (Video 35.2): In a small pupil and to avoid catching
• Release PAS before lysing posterior synechiae. iris, the key is to sweep the irrigation/aspiration tip circumferen-
• For pupils bound by membrane, strip the fibrotic band picking the clean tially under the anterior capsule to gather the cortex, stripping it
edge of the fibrous tissue using a capsulorrhexis microforceps. from the equator and aspirating the cortex only when the IA tip is
in the center of the bag and pupil.
318 PART VI Complex Cases

• After IOL insertion: Complete removal of OVD is difficult with • Formation of fresh posterior synechiae to the CCC rim and a
small capsulorrhexis, but it is necessary to avoid postoperative cap- resultant nondilating or nonconstriction of the pupil.
sular block syndrome. If the capsulorrhexis is too small, it should be • Cystoid macula edema.
enlarged at this stage, using the optic as a guide both for size and cen-
tration of the capsulotomy enlargement. This may be done by initiat-
ing a tearing edge using intraocular scissors or the Vannas scissors
HOW TO AVOID INTRAOPERATIVE
under OVD. The tear is then propagated around or just in the area SURGICAL COMPLICATIONS
needing expansion, ensuring complete CCC overlap of the optic. • If the pupil remains too small to perform phacoemulsification safely
• Prevention of fibrin formation: Consider injection of preservative (<4.0 mm diameter), it requires mechanical pupil dilatation for creation of
free dexamethasone intracamerally (0.4 mg/0.1 mL) in predisposed an adequately sized capsulotomy
eyes with noninfectious uveitis. • Patients at greatest risk for iris damage and atonic pupils after mechanical
dilation are those with iris tissue that cannot be stretched. Therefore use
mechanical dilators with caution.
POTENTIAL COMPLICATIONS
• In eyes with floppy iris, practice careful attention to wound construction
1. Intraoperative Complications (avoid short tunnels), timely use of iris retractors or pupil ring expanders, so
• A small pupil, if left unexpanded, inadvertently results in an as to reduce risk for iris billowing and facilitate safe phaco surgery.
inadequately sized capsulotomy (less than 4.5 mm); this, in turn, • Enlarge the capsulorrhexis after IOL insertion to reduce the risk for capsular
increases the difficulty of surgical maneuvering in the eye and phimosis.
predisposes to capsular phimosis.
• Intraoperative Complications that may develop include: • Linear lines of iris atrophy and irregular atonic pupils after
■ Iris trauma: iris prolapse, shredding, and bleeding from aspi- forceful extension of the pupil.18 The use of symmetric pupil ring
ration and phaco of the iris. expander devices may help distribute the stress forces of the iris
■ Hydrorupture, or posterior capsular rupture during more uniformly, to reduce postoperative iris damage.
hydrodissection, is predisposed by a small CCC. • Capsular phimosis, zonular dehiscence, and IOL dislocation.
■ Anterior capsule tears from a runaway capsulorrhexis or
from the chopper or phaco needle hitting the capsular rim
during phaco.
POSTOPERATIVE MANAGEMENT
■ IOL malposition: resulting from a CCC that is too small and • There is a greater risk for developing postoperative inflammation
difficult to visualize. The iris should be retracted at the end and CME with iris manipulation.
of the case to confirm that the haptics are both within the • For uncomplicated cataract surgery with small pupil associated
capsular bag. with PXE, narrow-angle glaucoma or IFIS, topical steroids (e.g.,
■ Posterior capsule rupture and vitreous loss resulting from Prednisolone acetate 1%), and NSAIDs together with prophylactic
extension of an anterior capsule rip. antibiotics should be commenced immediately after surgery and
■ Difficult visualization of the posterior capsule because of the continued for 4 to 6 weeks postoperatively depending on clinical
limited red reflex from a reduced pupil aperture. response.
■ Zonular dialysis: aspiration of the anterior capsule during • In patients with history of uveitis, there is a risk for severe inflam-
cortex removal because of the small capsulorrhexis and lim- matory response and the severity or duration of inflammation may
ited visualization of the cortex as a result of reduced pupil lead to reformation of posterior synechiae, CME, glaucoma, pupil-
aperture. It is important to ensure that the capsule is not lary membrane reformation, or even hypotony.19
engaged before centripetal movement of the I/A handpiece. ■ Consider oral steroids for prophylaxis in the preoperative or
■ Postoperative capsular block syndrome may result from early postoperative period to supplement the maintenance
inadequate removal of OVD from behind the IOL. immunosuppression.
° Mechanical pupil expansion itself can cause iris bleeding, ■ The addition of antiglaucoma medication may be necessary in
permanent loss of iris sphincter function, or a distorted cases of anticipated ocular hypertension.
pupil postoperatively. Tearing of the iris into the area ■ Conversely, eyes with chronic inflammation with a compro-
beyond the sphincter pupillae should be repaired using mised ciliary body function may become hypotonus with the
a modified Siepser sliding knot17 or its modification, the increased inflammation. Salvage measures such as intravenous
single pass four throw pupilloplasty. methyl prednisolone or intravitreal injection of a steroid drug
° Risk for iris damage is related to the state of the iris tissue delivery system may be necessary to save the eye.
and the forces applied during surgery (e.g., if there is there
is excessive traction on the iris retractor); this can lead to S U M M A RY
iris sphincter tears and bleeding. These risks should be
explained to patients with light- colored irises before sur- • Pay attention to meticulous wound construction. A corneal tunnel
gery and this may affect their appearance postoperatively. that is too short increases the risk for iris prolapse.
° In PXE, there is a risk for progressive zonular dehiscence, • Use of intracameral diluted adrenaline in BSS and inject visco-
therefore insertion of a capsular tension ring (CTR) is adaptive OVD to dilate the pupil and deepen the chamber before
advised. The CTR does not prevent zonulysis but may introducing pupil dilating devices.
make fixation of the dislocated IOL easier. • Fashion snug paracenteses pointing toward the pupil margin for iris
2. Postoperative Complications hooks that should include one placed in the subincisional location.
Postoperatively, from early to late, the following complications may • Iris hooks are preferred to pupillary ring expanders in small eyes,
be seen: shallow AC and when the iris is not stretchable and scarred, and
• Fibrin in the AC, especially if there is background of uveitis ± especially, when the surgeon is an infrequent user of pupil expander
exacerbation of uveitis. devices.
 CHAPTER 35 Cataract Surgery in the Small Pupil 319

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phimosis. cataract surgery. Curr Opin Ophthalmol. 2020;31(1):33–42.
• Postoperative management with adequate and rapid control of the 10. Akman A, Yilmaz G, Oto S, Akova YA. Comparison of various pupil
anterior chamber inflammation to prevent reformation of posterior dilatation methods for phacoemulsification in eyes with small pupil
secondary to pseudoexfoliation. Ophthalmology. 2004;111(9):
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1693–1698.
11. Chang DF. Use of Malyugin pupil expansion device for intraoperative
floppy-iris syndrome: results in 30 consecutive cases. J Cataract Refract
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 CHAPTER 35 Cataract Surgery in the Small Pupil 320.e1

Video 35.1 Video demonstrates removal of membranes causing Video 35.3 Video demonstrates the insertion and removal of iris
occlusio pupillae followed by pupil expansion with Malyugin ring. hooks, using a hook near the incision to prevent prolapse.
Video 35.2 Video demonstrates pupillary membrane stripping
followed by horizontal and vertical phacochop technique, keeping
phacotip within center of the pupil.