Phacoemulsillcation in a narrow pupil

Dr.H.AttarzadehAssociate Professor of

ophthalmology Isfahan University of medical

science

IntruductionGood mydriasis in one of the

Essential conditions for safety of the phaco

The operation can also be performed with a miotic pupill , using appropriate techniques

Narrow pupill observed in a bout 1.5% of cases

The narrow pupil is used when the pupill diameters is equal or less than 4m.m

Hyporeactive

Narrow pupil (functional) Fixed (anatomical)

Preoperative management

S.L.E – iridocorneal and iridolenticular synechia _ areas of Iris atrophy _ Paralysis of Iris muscles

Evaluation of mydriasis by phenyleferin 10% and tropicamid 1%

The degree of dilation (classification)

Excellent / good / suffcient / poor

Hyporeactive pupil (Functional)

Hyperopic patient Long period of antiglaucoma med .

Diabetes melitus

Fixed PupilPosterior synechia following uvreitis

Trauma NeurologicalOld ageChronic use of miotics

Techniques to manage a marrow pupill

Pharmacological Treatment Mydriasis using viscoelastics SynechiolysisPupillary strech Pupil dillatorsIris surgery

Pharmacological treatment

10% Phenylephe 3 time instilation

1 hour prior

to surgery

1% Tropicamide1% Cyclopentolate

_During surgery adrenalin 1/1000 diluted in 10 ml of B.S.S

ViscomydriasisViscoelastic substanse with high or very high molecular weight (Healon GV or Healon 5 ) is a good procedure to dilate the pupil for a good and larg capsulorhexis

SynechiolysisIn The cases of P. S. due to uveitis

Carefull synechiolisis with a blunt spatula

Pupillary stretchAfter having filled the A.C with viscoelastic

Pupill is streched with two hooks with centrifugal pressure (osher hook / iris retactors / craether hook )

Pupillary stretch

One – handed dilators also are available

(Beehler – keuch)

Pupil Dilators Even after pupillary stretcting

pupil may not be in sufficient dilation

In these cases the surgeon should use dilating hooks or iris rings

The most famous hook are Dejuan and Mackool

Dejuan hook are monofilament nylon thread

The Mackool hook are Titanium

Pupil dilation withIris ring

The most famous ring is Siepser,s hydrogel ring

When dehydrated , this is irregular oval shape and easily inserted through a 3mm Opening

When hydrated , it expands and is positioned over the pupil collarette

Nowaday C-shaped P.M.M A ditator is a not complete C shape ring

The empty portion of the ring is placed where the phaco tip operates

Iris SurgerySphincterotomy , Sphinctrectomy

Removal of the pupillary edge

IridectomyIris sutures

Sphincterotomy Produce a moderate mydriasisIt is usefull in senile miosis ,

postinflamatory miosis - long use of miotics

A fine microscissor ( vitreoretinal ) is prefereble6-8 radial incisions for 2/3 of

the length of the iris sphincter

Removal of the pupillary Edge

The pupillary fibrotic ring is catch by a fine forcepse and gently is pulled out

Any bleeding will kept under control by injection of V.E.A

IridectomyWhen the iris is atrofic and sclerotic

At the and of surgery . The rearrangement of the iris is obtained by iridoplasty