Phacoemulsillcation in a narrow pupil

2. Phacoemulsillcation in a narrow pupil Dr.H.Attarzadeh Associate Professor of ophthalmology Isfahan University of medical science

4. Intruduction • Good 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

5. Hyporeactive • Narrow pupil (functional) Fixed (anatomical)

6. 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%

7. The degree of dilation (classification) • Excellent / good / suffcient / poor

8. Hyporeactive pupil(Functional) • Hyperopic patient • Long period of antiglaucoma med . • Diabetes melitus

10. Fixed Pupil • Posterior synechia following uvreitis • Trauma • Neurological • Old age • Chronic use of miotics

11. Techniques to manage a marrow pupill • Pharmacological Treatment • Mydriasis using viscoelastics • Synechiolysis • Pupillary strech • Pupil dillators • Iris surgery

12. Pharmacological treatment 10%Phenylephe 3 timeinstilation 1 hourprior to surgery 1%Tropicamide 1%Cyclopentolate _During surgery adrenalin 1/1000 diluted in 10 ml of B.S.S

13. Viscomydriasis • Viscoelastic 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

16. Synechiolysis • In The cases of P. S. due to uveitis • Carefull synechiolisis with a blunt spatula

18. Pupillary stretch • After having filled the A.C with viscoelastic • Pupill is streched with two hooks with centrifugal pressure (osher hook / iris retactors / craether hook )

20. Pupillary stretch • One – handed dilators also are available (Beehler – keuch)

23. 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

27. 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 3mmOpening • When hydrated , it expands and is positioned over the pupil collarette

32. 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

33. Iris Surgery • Sphincterotomy , Sphinctrectomy • Removal of the pupillary edge • Iridectomy • Iris sutures

34. Sphincterotomy • Produce a moderate mydriasis • It is usefull in senile miosis , postinflamatory miosis - long use of miotics • A fine microscissor ( vitreoretinal ) is prefereble • 6-8 radial incisions for 2/3 of the length of the iris sphincter

37. 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

39. Iridectomy • When the iris is atrofic and sclerotic • At the and of surgery . The rearrangement of the iris is obtained by iridoplasty