Today’s PracTice caTaracT FundamenTals

E yes with small pupils present a challenge to cataract surgeons. A pupil that fails to dilate can obscure visualization during all stages of phacoemulsification, making surgery more difficult and increasing the incidence of complications such as nucleus drop, vitreous prolapse, and iris tear. Inadequate pupil dilation is often seen in patients with a history of use of miotic agents, chronic uveitis, diabetes mellitus, pseudoexfoliation syndrome, intraoperative floppy iris syndrome (IFIS), iris trauma, and rubeosis iridis. Fortunately, the availability of several intraoperative techniques and pupil-expanding devices enables phacoemulsification to be performed even in these difficult eyes. Strategies for enlargement primarily depend on the surgeon’s skill level and preference and on the individual intraoperative situation. This article presents pearls for a variety of methods used to facilitate phacoemulsification in patients with small pupils. For a video demonstration of the methods described for phacoemulsification in small pupils, visit eyetube.net/?v=deedq.