Tips ease challenges of cataract surgery in small pupils with angle-closure glaucoma

Cataract surgery in eyes with angle-closure glaucoma can present the need for small pupil management techniques, said Murray Johnstone, MD. Dr. Johnstone reviewed several pearls for handling these challenging cases at Glaucoma Day at the American Society of Cataract and Refractive Surgery meeting.

The paracentesis is the first critical consideration, and it should be deep and posterior to minimize problems with iris prolapse and sweeping. If posterior synechia are present, they should be freed with a Kuglan hook, and that step should be done before using a pupil stretching device, said Dr. Johnstone, of the University of Washington, Seattle.

For pupil stretching, he indicated his preference is to use a three-way pupil expander rather than two Kuglan hooks because the former provides relatively uniform dilation and a more cosmetically acceptable end result.

Fibrosis of the anterior capsule presents another common challenge in patients with miotic, bound-down pupils. If problems are encountered in creating the capsulorhexis, a Vannas scissors can be used to cut through the fibrotic material so that the capsulotomy can be brought around from the other direction.

For lens manipulation, use of a Conner Wand to elevate the nucleus hemispheres and to hold them in place during phacoemulsification allows nucleus removal to be carried out in the center of the pupil and without zonular stress.

"With this technique, the surgeon always has direct visualization and maintains full control throughout phacoemulsification," he said.