Small Pupil Clear Corneal Phacoemulsification Surgery

The increased acceptance of topical anesthesia, phacoemulsification and foldable intraocular lenses (IOLs), have advanced the techniques of microincision clear corneal cataract surgery.1 Operating through these small (less than 3.0 mm), corneal incisions have placed new demands on surgeons to effectively and safely remove the cataract and implant the IOL without increasing the risk of corneal, iris or capsular damage. The causes of small pupil include atrophy or iris sphincter sclerosis as a result of aging, synechiae, previous trauma, surgery, diabetes, iridoschisis, uveitis, chronic miotic therapy, or pseudoexfoliation. The small pupil (less than 3.0 mm) can impede visualization and makes maneuverability of the instrumentation into the eye more difficult (Fig. 40.1). Capsulorrhexis may be difficult to perform in a small pupil. Hydrodissection and phacoemulsification of the lens nucleus can lead to an increased risk of iris sphincter tear, bleeding, iris emulsification, ruptured posterior capsule and loss of the nucleus. Small pupil is associated with increased operative time, risk of complications, discomfort for the patient and surgeon apprehension. Postoperatively, these may lead to an irregular or atonic pupil, photophobia and an unacceptable cosmetic and functional result.