gms | German Medical Science

Cataract surgery in patients with small pupil is a well-known challenge. Currently there are various emerging trends in that area starting from novel pharmacological approaches and extending towards the surgical pupil expansion devices. This lecture will provide critical review of the available options including their advantages and possible limitations to be considered by the surgeon.

The intracameral use of various mydriatic combinations augmenting the preoperative mydriatic instillations is currently gaining popularity in cataract surgery. Two main options are available: bolus injection of pharmacological agent or its constant irrigation during the phacoemulsification procedure. The former is aimed to expand the pupil, while the latter is mostly preventing the pupil from constriction.

Introduction of femtosecond assisted cataract surgery, apart from some benefits was followed by a variety of adverse effects including prostaglandin release into the aqueous humor causing pupil constriction. Preoperative administration of non-steroidal anti-inflammatory drugs at least one day prior to surgery significantly decreases the chance of pupil constriction after laser energy is applied to the eye.

In spite of the overall success of pharmacological pupil dilation, mechanical pupil expansion devices may be needed in up to 10% of cases. Following the success of the Malyugin Ring several manufacturers introduced pupil expansion devices of various designs. They are differing with materials, pupillary margin fixation mechanisms, and easiness of manipulations during implantation and removal.

Combination of proper use of pre- and intraoperative pharmacological pupil dilatation protocols and pupil expander rings allow for safe and effective cataract surgery in the vast majority of patients with insufficient mydriasis.