Phacoemulsification in eyes with a small pupil

PURPOSE: To evaluate the intraoperative difficulties and long-term outcome of phacoemulsification through a small pupil using minimal iris manipulation. SETTINGS: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. METHODS: This prospective study included 30 consecutive eyes with a maximally dilated pupil size of 4.0 mm or smaller. Except synechiolysis and occasional pupil retraction with a chopper, no iris manipulation was performed. The phacoemulsification technique included creation of deep central space, use of a low aspiration flow rate with appropriate vacuum, and step-by-step chop in situ and lateral separation of the nucleus. Patients were examined 1 day, 1 week, 1 and 3 months, and 1 year postoperatively. Specular microscopy was performed at 1 month and 1 year. RESULTS: Fourteen eyes had chronic iritis, 12 had glaucoma surgery, 2 had pseudoexfoliation, and 2 had a rigid pupil. Mean follow-up was 13.6 months. Eighteen eyes (60%) had hard cataract. Mean preoperative pupil size was 2.80 mm +/- 0.75 (SD). Mean pupil size before the capsulorhexis was initiated was 4.42 +/- 0.58 mm. The iris was bruised in 10 eyes during cortex removal. Trace amounts of cortex were left in 4 cases. Two eyes had increased intraocular pressure in the early postoperative period. Six patients had a minimal amount of retained viscoelastic material (pseudofibrin), and 2 patients developed a sterile hypopyon. Sixteen eyes had cell deposits on the IOL surface and 12 eyes, fine uveal pigments. In 2 eyes with previous glaucoma surgery and in all eyes with iritis except 2, posterior synechias reformed. CONCLUSIONS: Successful phacoemulsification was done with minimal or no pupil-widening maneuvers, restoring the preoperative pupil configuration.