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

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  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

Hyporeactive  Narrow pupil (functional) Fixed (anatomical) 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%  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  Hyperopic patient  Long period of antiglaucoma med.  Diabetes melitus

Fixed Pupil  Posterior synechia following uvreitis  Trauma  Neurological  Old age  Chronic use of miotics  Posterior synechia following uvreitis  Trauma  Neurological  Old age  Chronic use of miotics

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

Pharmacological treatment 10% Phenylephe 3 time instilation 1 hour prior to surgery 1% Tropicamide 1% Cyclopentolate _During surgery adrenalin 1/1000 diluted in 10 ml of B.S.S 10% Phenylephe 3 time instilation 1 hour prior to surgery 1% Tropicamide 1% Cyclopentolate _During surgery adrenalin 1/1000 diluted in 10 ml of B.S.S

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

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

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 )  After 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)  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  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 with Iris 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  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  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 Surgery  Sphincterotomy, Sphinctrectomy  Removal of the pupillary edge  Iridectomy  Iris sutures  Sphincterotomy, Sphinctrectomy  Removal of the pupillary edge  Iridectomy  Iris sutures

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  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

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  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

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