Small pupils: Maneuvers, medications, mechanical devices

Eyes with small pupils create challenges for cataract surgery and are at increased risk for intraoperative complications.

During the Spotlight on Cataract session at American Academy of Ophthalmology  2016, Thomas A. Oetting, MD, MS, shared five pearls for operating in eyes with small pupils. In the follow-up discussion, panel members commented on their experiences with newer options for small pupil management.

1. Iris hooks

Dr. Oetting’s first tip addressed the use of iris hooks, and he recommended that the incisions for their placement be made very posterior and very flat.

In a video, Dr. Oetting demonstrated using a 26-gauge bent needle to create the incisions without the use of viscoelastic. He noted that he places the hooks in a diamond configuration with the main incision over one of the hooks.

“This approach makes iris prolapse nearly impossible,” said Dr. Oetting, clinical professor of ophthalmology and visual sciences, University of Iowa.

Pearl 2

2. Pupil expansion rings

For his second tip, Dr. Oetting reminded surgeons that 6.5 mm is greater than 6.25 mm. The obvious statement related to a case where he wound up implanting an IOL with a 6.5-mm optic after placing a 6.25-mm Malyugin Ring (MicroSurgical Technologies). His intraoperative video showed how the lens became entangled in the pupil stretching ring.

“Make sure in this situation that before the IOL uncurls, it is posterior to the Malyugin Ring,” he said.

3. Iris prolapse

Dr. Oetting’s third tip focused on techniques for managing iris prolapse, which he noted often occurs late in the case after removal of any pupil stretching device. One method involved stroking the wound after releasing fluid from the eye through the paracentesis. If that fails, Dr. Oetting showed how surgeons can create a jetstream inside the eye by simply squirting the surgical incision with the cannula.

Pearl 4

4. Eddy currents

Noting that retained lens material is a common problem in eyes with small pupils, Dr. Oetting’s fourth tip recommended creating eddy currents in the anterior chamber to help bring the fragments forward. This maneuver is done at the end of the case after hydrating the paracentesis, and Dr. Oetting said he has found it helpful for limiting the need to bring patients back to the operating room for a secondary procedure.

5. Retained nuclear material

Dr. Oetting’s fifth tip related to postoperative management of eyes with retained nuclear material. In this situation, Dr. Oetting showed how he uses the inserter for the Malyugin Ring for fragment retrieval after using viscoelastic to move and sequester the fragment centrally.

“Going in with I&A will below the piece away, and you will never find it,” he cautioned.

New pupillary aids

New pupillary aids

During the panel discussion, Boris Malyugin, MD, PhD, deputy director, S. Fyodorov Eye Microsurgery Institution, Moscow, discussed the latest modification of his pupil ring-the Malyugin Ring 2.0.

He explained the product’s name reflects the fact that it can go through a 2.0-mm incision. Made of 5-0 polypropylene rather than 4-0 polypropylene, the new version of the Malyugin Ring is thinner and more flexible than earlier generations, which also makes insertion and removal of the ring easier.

Terry Kim, MD, professor of ophthalmology, Duke University Eye Center, Durham, NC, discussed his experience using the I-Ring Pupil Expander (Beaver-Visitec). Made of polyurethane, Dr. Kim noted this device is also very flexible and can be injected through a 2.4-mm incision.

“The I-Ring is very soft, easy to manipulate, very gentle to the pupil edge and sphincter, and it can be removed using just a Sinskey hook,” Dr. Kim said.

Both Richard L. Lindstrom, MD, and Eric D. Donnenfeld, MD, discussed their experience with intracameral phenylephrine and ketorolac injection 1%/0.3% (Omidria, Omeros).

Asked about the use of pupil stretching, Dr. Lindstrom, adjunct professor emeritus, Department of Ophthalmology, University of Minnesota, Minneapolis, noted he rarely finds any need to use that technique anymore thanks to the efficacy of the commercially available pharmacological dilating agent combined with viscodilation as needed.

Dr. Donnenfeld, clinical professor of ophthalmology, New York University, New York, described intracameral phenylephrine/ketorolac as the single most helpful thing surgeons have to prevent pupil constriction in patients with intraoperative floppy iris syndrome (IFIS).

He noted that results of a clinical trial he conducted found the intracameral combination product was dramatically more effective than intracameral epinephrine alone for maintaining pupil dilation in eyes with IFIS or small pupils.