Small pupils not only can lead to increased surgical times and difficulty in removing the cataract but also are associated with a higher complication rate, including posterior capsular rupture. Every surgeon has their own definition of what constitutes a small pupil and what technique (eg, pharmacologic, stretching) and/or device (eg, overfill with ophthalmic viscosurgical devices, iris hooks, various iris ring expanders) they favor depending on the situation/patient.
In a recent retrospective case series,[1] Nderitu and Ursell compared outcomes with two of the most common device-based approaches to addressing the small pupil: iris expansion rings and iris hooks. They examined case time and complication rate during cataract removal, performed by both attending-level consultant surgeons and trainees using these separate devices.
As would be expected, they found that iris rings were faster than iris hooks for both consultants and trainees. The additional time required to use hooks in both groups was significant when compared with the use of rings for standard cases. Intraoperative complication rates did not increase in cases using either pupil expander, and final visual outcomes were comparable.
Nderitu and Ursell did find that iris rings were associated with significantly higher rates of postoperative anterior uveitisand corneal edema. This is not unexpected, as any manipulation of the iris can lead to increased postoperative inflammation.
