Small Pupil Phacoemulsification

Used to be relative contraindication

for phacoemulsification

Causes of small / rigid pupil

AgeSynechiaePseudoexfoliationDiabetes MellitusMiotics(Pilocarpine)

Pre op evaluation

➲ Surgical planning

Plan of surgery

Stop miotics 12 to 24 hours before surgeryUse of NSAID - Flurbiprofen 0.03%

(Maintain - Diclofenac 0.1%

Dilatation) - Ketorolac 0.5% Intraop epinephrine (non preserved)

1 : 1000 0.5ml per 500 ml of fluidAnesthetics → then drop

Intra op Dilatation- pharmacological Viscodilatation- HPMC - High molecular weight e.g. Healon 5 Sphincterotomy with Vannas scissors with

Viscodilatation Iris hooks / Retractors (Sphincter damage) Cold irrigating fluid-Add adrenaline Expander rings Thick / Maximum pupil size 6 to 7 mm Beehler pupil expander Stretch pupiloplasty – Stretch only once Capsules stain – Aim for 5 mm rhexis

Pseudoexfoliation – Zonular dehiscence

reengage hooks from capsule Iris schhaffing Iridodialysis (hypermetropia) Floppy Iris – α agonist

- Prostrate treatment

Implications Problems due to small Pupil

Small rhexis Hard nucleus / soft nucleus

– Posterior polar

- Leathery nucleus Visibility AC shallow due to iris retraction

Chances of iris trauma increase Posterior synechiae – Pupil release with iris

spatula

-Pupillary membrane stripoff

Post op

CycloplegicSutures for side portsAir in ACSteroids

Iris hooks

Pseudoexfoliation.

PosteriorSynechiae