Phacoemulsillcation in a narrow pupil

Phacoemulsillcation in a narrow pupil

Dr.H.AttarzadehAssociate Professor of

ophthalmology Isfahan University of medical

science

Dr.H.AttarzadehAssociate Professor of

ophthalmology Isfahan University of medical

science

IntruductionIntruductionGood 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 managementPreoperative 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)

The degree of dilation (classification)

Excellent / good / suffcient / poor

Excellent / good / suffcient / poor

Hyporeactive pupil (Functional)

Hyporeactive pupil (Functional)

Hyperopic patient Long period of antiglaucoma med .

Diabetes melitus

Hyperopic patient Long period of antiglaucoma med .

Diabetes melitus

Fixed PupilFixed PupilPosterior synechia following uvreitis

Trauma NeurologicalOld ageChronic use of miotics

Posterior synechia following uvreitis

Trauma NeurologicalOld ageChronic use of miotics

Techniques to manage a marrow pupill

Techniques to manage a marrow pupill

Pharmacological Treatment Mydriasis using viscoelastics SynechiolysisPupillary strech Pupil dillatorsIris surgery

Pharmacological Treatment Mydriasis using viscoelastics SynechiolysisPupillary strech Pupil dillatorsIris surgery

Pharmacological treatmentPharmacological treatment

10% Phenylephe 3 time instilation

1 hour prior

to surgery

1% Tropicamide1% 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% Tropicamide1% Cyclopentolate

_During surgery adrenalin 1/1000 diluted in 10 ml of B.S.S

ViscomydriasisViscomydriasisViscoelastic 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

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

SynechiolysisSynechiolysisIn 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 stretchPupillary 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 Pupillary stretch

One – handed dilators also are available

(Beehler – keuch)

One – handed dilators also are available

(Beehler – keuch)

Pupil Dilators 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 withIris ring

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 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 SurgeryIris SurgerySphincterotomy , Sphinctrectomy

Removal of the pupillary edge

IridectomyIris sutures

Sphincterotomy , Sphinctrectomy

Removal of the pupillary edge

IridectomyIris sutures

Sphincterotomy Sphincterotomy

Produce a moderate mydriasisIt is usefull in senile miosis ,

postinflamatory miosis - long use of miotics

A fine microscissor ( vitreoretinal ) is prefereble6-8 radial incisions for 2/3 of

the length of the iris sphincter

Produce a moderate mydriasisIt is usefull in senile miosis ,

postinflamatory miosis - long use of miotics

A fine microscissor ( vitreoretinal ) is prefereble6-8 radial incisions for 2/3 of

the length of the iris sphincter

Removal of the pupillary EdgeRemoval 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

IridectomyIridectomyWhen 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