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�"#0G#�!R�'/"�'N"�'*N"diiQiiiii�"�"QiiiG#iiii���������������������������������������������������������������������'iiiiiiiii� �:	@Push and pull method for small incision cataract surgery in small pupil- An innovative technique


Abstract:

A significant number of patients who present for cataract surgery have pupils that do not respond adequately despite several pharmacological attempts with different mydriatic agents. Most of the current available surgical maneuvers for enlarging the pupil and preventing its intraoperative constriction are not safe enough. They can lead to an increased risk of iris sphincter tear, bleeding, iris damage, posterior capsule tears, and loss of the vitreous body. The postoperative complications can include an atonic pupil of irregular shape leading to poor visual and cosmetic result. Large pupils postoperatively are associated with glare and a reduced depth of focus. We present our innovative technique �Push and pull method �for small incision cataract surgery in small pupil. This push and pull method of pupillary dilatation minimizes the likelihood of iris sphincter tear, thereby leading to no postoperative irregular dilated pupil and glare and better visual outcome.
Key words : small pupil, Push and pull method, Sics

Introduction:
Small pupil size still poses a challenge for any cataract surgeon. Many patients fail to show adequate response to pharmacological agent preoperatively,resulting in poorly dilated pupil less then 5mm. Poor pupil dilation can be observed in cases complicated by pseudoexfoliation syndrome, uveitis, posterior synechiae, trauma or previous intraocular surgery [1-6]. A pupil that fails to dilate can obscure visualization during all stages of cataract surgery from capsulorrehxis to IOL implantation, making surgery more difficult and increasing the incidence of complications such as nucleus drop, vitreous prolapse, and iris tear. Most of the surgeons decide to dilate the pupil mechanically at the time of surgery if pharmacological agents fail. There are four main dilation methods: the first is the synechiolysis, the second is mechanical stretching, the third is the cutting method and the fourth is the iris retraction. Any technique that incises, stretches, or otherwise deforms the pupil risks a poor cosmetic result. Additionally, an irregular or unacceptably large pupil may have detrimental visual consequences. Large pupils are associated with glare and a reduced depth of focus[7]. Trauma to the iris may incite the development of posterior synechiae. Insertion, positioning,and removal of iris retraction devices(iris hooks,malyugin ring)  can take a significant amount of time and also add to additional cost for surgery.
To overcome the problem of post operative mydriasis and glare associated with previously established techniques of pupillary dilations , in this study we have described an innovative technique of pupillary dilatation �push and pull method � in small pupil that allowed us to perform SICS smoothly and efficiently  as well as mimimize the post operative  permanent pupilary dilatation & glare.
Surgical technique:
We tried to dilate pupil preoperatively using 10% phenylephrine and 1% tropicamide and 1% cyclopentolate which were instilled three times during the hour prior to surgery. The surgery was done under peribulbar  block.The peribulbar injection consisted of a mixture of 2 ml 2% lignocaine and 2 ml 0-5% bupivacaine with 1/200 000 adrenaline in which was dissolved 1500 IU hyaluronidase, followed by 10 minutes of gentle manual bulbar compression. Standard SICS steps were followed for making tunnel and entry in AC. Anterior capsule was stained with tryphan blue dye for better visualisation. Synecheia if present were broken by sweeping the iris repositor between iris and lens capsule. Viscomydriasis was attempted by injecting high molecular cohesive viscoelastic Healon GV or Healon 5. Capsulorexhis  was done by our new push and pull method. We created a side port entry and introduced a Y shape hook through it. (Fig 1). Cystitome or utrata was introduced through main incision. Initially the iris tissue is pushed away from the hook (Fig 2a ) which allows better visualisation of anterior capsule and rhexis is initiated(Fig 2b), then the hook is gradually moved along the pupilary border  in anticlockwise manner from ( 3- 9 o clock) at the same time pushing the iris tissue away allowing  better visualisation of anterior capsule and continue  rexhis in small quadrant wise (Fig 2c,2d,2e). When the rexhis comes to 9 o clock the iris is pulled with the sinskey hook towards the side port and rexhis is further continued (Fig 2f). Then we gradually move the hook in anticlockwise manner along the pupilary border simultaneously pulling the iris tissue towards the hook giving good visualisation to continue capsulorexhis  in small segment wise (Fig 2g,2h,2i,2j) and  thus  capsulorexhis is completed (Fig 2k,2l).In this way by pushing and pulling  iris tissue centifugally with the help of Y hook and sinskey Hook (Fig 3) respectively as per the need we can perform capsulorexhis in small pupil without damaging the iris sphincter.
Good hydrodelination decreases size of nucleus and enables it to prolapse in AC in small pupil. The Amount of hydro should be minimal as it prevents iris engagement in tunnel due to pupilary block. It also prevents posterior capsular rupture which may be caused by increase pressure built due to large amount of BSS which is unable to pass through small blocked pupil.  Press the nuclear edge slightly to spread the pressure in the sac and to let the fluid escape and to have better cleavage of lens substance.
Bimanual technique of nucleus prolapse in AC is best suited for small pupil. In this technique two instrument are used Sinskey hook and iris repositor or cyclodialysis spatula.(Fig 4a) Pupillary margin of iris is gently retracted, then hook is embedded in the nucleus at the edge of equator at 9 o clock in the right eye and 3 o clock in left eye  and slightly lifted (Fig 4b,4c). With the other instrument the nucleus is pushed backward at opposite pole which lifts this pole of the nucleus. Using the  instrument from side port  as fulcrum to lift the nucleus up , the nucleus is rotated either clockwise or anticlockwise with sinskey hook out of capsular bag.(Fig 4d,4e) The instruments are embedded repeatedly at proximal site and the nucleus is rotated out.(Fig 4f)This technique also decreases stress on the zonules by transferring the force on to the fulcrum.
We followed the irrigating wire vectis technique for nucleus removal, it is important to start irrigation via vectis once vectis has engaged the nucleus in the wound never before. Because chances of iris coming out in tunnel increases in small pupil. In small pupil always aspirate the cortical matter after bringing it out from periphery in the pupillary area. It is easy to pull subincisional cortex via J-shaped cannula/side port made in inferior quadrant. If some cortex is left it is safe to implant IOL first and then do rest of cleaning. IOL  implantation is difficult due to poor visualisation of rhexis, shallow AC, considerable posterior pressure and zonule weakness in few cases.  Two viscoelastic substances are used one cohesive for capsular sac and other adhesive for anterior chamber to have space in capsular bag and protect the corneal endothelium. Leading haptic is put in the bag by tilting the lris slightly posteriorly then IOL  is put in the bag by rotating it holding trailing haptic with forceps. VES should be removed as completely as possible.  It is easier to remove cohesive  VES than adhesive one. Cohesive VEs is remove by putting gentle pressure over the edge of lens allowing VES  to escape in AC and then it is  removed from there. For adhesive VES we go behind the optic to ensure complete removal  of VES , but it is difficult in small pupil where rhexis margin are not well visualized.

Discussion:
Small pupils make surgery especially demanding, increasing the likelihood of intraoperative complications and poor visual and cosmetic results. If visualization is poor, every step of cataract surgery beyond making the incision becomes difficult. A small pupil can obscure the view of the
anterior capsule and make the capsulorhexis difficult. A small pupil can impair the view of the cataract and posterior lens capsule, increasing the likelihood of posterior capsular rupture, dropped lens fragments, incomplete cortical clean-up, and vitreous loss. A significant number of patients who present for cataract surgery have pupils that do not respond adequately despite several pharmacological attempts with different mydriatic agents. Most of the surgical maneuvers for enlarging the pupil and preventing its intraoperative constriction are not safe enough. They can lead to an increased risk of iris sphincter tear, bleeding, iris damage, posterior capsule tears, and loss of the vitreous body. The postoperative complications can include an atonic pupil of irregular shape with poor cosmetic result, and photophobia.

There are four main dilation methods: the first is the synechiolysis, the second is cutting method, the third is the mechanical stretching and the fourth is the iris retraction.Whenever posterior synechiae are present, they should be broken. Synechiolysis can be performed usinga cyclodialysis spatula, viscoelastic canula, or any blunt-tipped instrument. In many cases ever after synechiolysis , other methods like sphicterotomy or stretch pupilloplasty  are required to maximize dilation. The earliest and crudest technique for enlarging small pupils involved cutting the iris stroma or sphincter muscle[8]. Because a surgical iridectomy produces a significant cosmetic deformity, it is no longer recommended. In  sphincterotomy , small radial cut through the iris sphincter muscle is made. It is usually performed with Vannas or other intraocular scissors. After multiple sphincterotomies are made, most pupils appear slightly irregular.Fine advocates making several partial sphincterotomies and, if necessary,stretching the pupil[2]. He reports acceptable cosmesis with this approach. Both  iridectomy and sphincterotomy techniques involve a significant amount of iris manipulation leading to intraoperative bleeding, postoperative hyphema and postoperative inflammation. Stretch pupilloplasty, as described by Miller and Keener Jr.,[9] and Shepard[10] and subsequently documented in video format by Fry (Fry L: Pupil Stretching.Video J Cataract Refractive Surg 6, 1995), uses a pair of Kuglen hooks to stretch the pupil in one or more directions. This maneuver creates microscopic sphincter tears which enlarge the pupil aperture. The drawback of stretching technique is that it creates permanent damage of the iris sphincter leading to postoperative mydriasis and glare. Also the micro tears of the sphincter muscle sometimes result in bleeding and pigment dispersion postoperatively. After it is stretched, an iris maybe floppy and a floppy iris is more likely to aspirate into the phacoemulsification probe or prolapsed through the cataract incision during surgery. In a study of stretch pupilloplasty by Dinsmore 10 % of 50 patients developed an enlarged atonic pupil postoperatively[11]. For the iris retraction several devices have been introduced in the clinical practice.The main disadvantages of these devices include the bulkiness and rigidity. They are difficult to insert, remove, and manipulate through a small incision. Flexible (de Juan, Grieshaber, a division of Alcon, Ft. Worth, TX) or rigid (MacKool, Duckworth and Kent, Hertfordhire, U.K.) iris retractors are used by some surgeons[12,13]. Insertion, positioning, and removal of these hooks can take a significant amount of time. Secondly since it involves stretching iris simulatenously at more the one point, sphincter damage can occur leading to postoperative poor visual function and cosmesis due to irregular dilated pupil. Masket [14] and Yuguchi and coauthors [15] recommend the pupil not be stretched by the hooks to larger than a 5.0 mm square because overstretching produces irregular atonic pupils postoperatively .During engagement of the pupillary edge with the iris hook, it may catch and damage the capsule, leading to an anterior capsule tear that may extend to the periphery.

Our push and pull method for pupillary dilatation have several advantages. Firstly since there was either pushing or pulling of iris in only one direction each clock hour at a time unlike stretch pupilloplasty and iris retraction ,there was no chance of iris sphincter damage or floppy iris. Secondly as the pupillary dilatation  by our method was done each clock hour at a time exposing the progressing tear of anterior capsule. Thirdly , the iris manipulation is less compared to other methods decribed earlier hence there is less chance of intraoperative bleeding, postoperative hyphema and postoperative inflammation .Finally the most important adavantage was that  there was no postoperative permanent pupillary dilatation, which leads to better visual acuity and cosmesis and no glare.



Conclusion: With our innovative technique of �Push and pull method� for pupillary dilatation  in small pupil,we could perform SICS smoothly and efficiently  without damaging the iris sphichter thereby leading to no postoperative irregular dilated pupil and glare.

References:

Drolsum L, Haaskjold E, Davanger M. Results and complications after extracapsular cataract extraction in eyes with pseudoexfoliation syndrome. Acta Ophthalmol (Copenh) 1993; 71:771�776

Fine IH. Pupilloplasty for small pupil phacoemulsification. J Cataract Refract Surg 1994; 20:192�196

Gimbel HV. Nucleofractis phacoemulsification through a small pupil. Can J Ophthalmol 1992; 27:115�119

Kershner RM. Management of the small pupil for clear corneal cataract surgery. J Cataract Refract Surg 2002;28:1826�1831

Smith GT, Liu CSC. Flexible iris hooks for phacoemulsification in patients with iridoschisis. J Cataract Refract Surg 2000; 26:1277�1280

Vasavada A, Singh R. Phacoemulsification in eyes with a small pupil. J Cataract Refract Surg 2000; 26:1210�1218.

Masket S: Relationship between postoperative pupil size and disability glare.J Cataract Refract Surg 18: 506-7,1992.

Cole MD, Brown R, Ridgway AE: Role of sphincterotomy in extracapsular cataract surgery. Br J Ophthalmol 70:692-5, 1986.

Miller KM, Keener GT Jr: Stretch pupilloplasty for small pupil phacoemulsification. Am J Ophthalmol 117:107-8, 1994

Shepherd DM: The pupil stretch technique for miotic pupils in cataract surgery.Ophthalmic Surg 24: 851-2, 1993.

Dinsmore SC. Modified stretch technique for small pupil phacoemulsification with topical anesthesia. J Cataract Refract Surg 1996; 22: 27�30.

de Juan E Jr, Hickingbotham D: Flexible iris retractor. Am J Ophthalmol 111: 776-7, 1991

Mackool RJ: Small pupil enlargement during cataract extraction. A new method. J Cataract Refract Surg 18:523-6, 1992.

Masket S. Avoiding complications associated with iris retractor use in small pupil cataract extraction. JCataract Refract Surg 1996; 22:168�171.

Yuguchi T, Oshika T, Sawaguchi S, Kaiya T. Pupillary functions after cataract surgery using flexible iris retractor in patients with small pupil. Jpn J Ophthalmol 999; 43:20�24

Figure legends

Figure 1 - Making of sideport
Figure 2 -  Steps of  Capsulorhexis
Figure 3 - Instruments (Y hook)
Figure 4 - Bimanual technique of nucleus prolapse
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