EyeWorld India December 2014 Issue

13 December 2014 EWAP FEATURE Cataract surgery and the small pupil by Michelle Dalton EyeWorld Contributing Writer Regardless of the cause, performing cataract surgery on patients with small pupils is no easy task O ne of the more complicated variables when planning for cataract surgery is small pupils in a patient. The causes are widespread, and often they require the use of hooks or rings to prevent the pupil from coming down intraoperatively, and lens fragments may be more difficult to see. But by understanding the causes and how to manipulate the iris, surgeons can be confident of successful postoperative outcomes, experts say. For example, if the small pupil is a result of pseudoexfoliation, once it is stretched the iris “usually will not rebound back to its original small state,” said Laura K. Green, MD , residency program director, Krieger Eye Institute, Baltimore, Md., U.S., and in private practice at Sinai Physician Partners, Baltimore, Md., U.S. If the cause is uveitis, after pupil stretching the “pupil may not be perfectly round and regular ever again,” she said. Michael Summerfield, MD , founder, Washington Eye Institute, Washington, DC, U.S., and residency program director, Georgetown University/ Washington Hospital Center, recommends using pupil expanders in all small pupil cases. “Over time, I’ve become a little bit more liberal with the use of the Malyugin ring [MicroSurgical Technology, Redmond, Wash., U.S.] because it doesn’t add a lot of case time,” he said, but in cases of potential intraoperative floppy iris syndrome (IFIS) or in rare cases when the iris prolapses to the main phaco incision, he will opt for iris hooks instead. Dr. Green is “comfortable operating through a 5 mm pupil if that enables me to perform the surgery without the need for any hooks.” She noted hooks could be used without permanently stretching the pupil. Toric IOLs and small pupils Couple small pupils with patients who want toric lenses and “it’s important to have a low threshold to use a pupillary expansion device, especially where you need to see the marks for alignment,” said Preeya K. Gupta, MD , assistant professor of ophthalmology, Duke University School of Medicine, and clinical director, Duke Eye Center at Page Road, Durham, NC, U.S. Visualization and alignment are “by far” the most difficult issues when placing a toric lens in a patient with small pupils, Dr. Summerfield said. “One potential problem is when you’re removing the viscosurgical device (OVD) from the bag,” he said. “Sometimes the lens needs to be pushed aside and that may result in the lens spinning. My advice is to check lens position, remove the OVD, and then recheck once you’ve finished.” While Dr. Green will use toric lenses in patients with IFIS or diabetes, “I do not feel comfortable using them in patients with scarring conditions of the pupil.” Centration is not a considerable factor as long as the capsule is intact, she said. “The IOL itself will AT A GLANCE • Have a low threshold to use a pupillary expansion device in eyes with small pupils. • Be wary of all alpha-blockers, not just tamsulosin, as potential IFIS causes. • More women are developing IFIS. • Clean as you go to avoid hidden lens fragments. Patient with pseudoexfoliation syndrome and small pupils Late subluxation of IOL in an eye with pseudoexfoliation syndrome Source: Bonnie An Henderson, MD continued on page 14