Title : Optimizing small pupil phaco: 12 year evolution in high risk cases
Abstract:
Title: Optimizing Small Pupil Phacoemulsification: 12-Year Single-Surgeon Evolution in 1,142 High-Risk Cases
Purpose: To evaluate the safety, efficacy and progressive complication reduction achieved through sequential adoption of pupil expansion techniques in high-risk small-pupil cataract surgery over 12 years.
Methods: Retrospective consecutive series of 1,142 eyes with pupil ≤4.0 mm after pharmacologic dilation operated by a single surgeon (Jan 2012 – Dec 2024). High-risk features: pseudoexfoliation 38%, prior acute angle-closure 12%, chronic miotics 18%, uveitic synechiae 14%, IFIS 18%.
Techniques evolved in four phases:
- Phase 1 (2012–2015, n=360): viscodilation + bimanual stretching
- Phase 2 (2016–2018, n=180): 4–6 iris retraction hooks
- Phase 3 (2019–2022, n=352): B-HEX pupil expansion ring
- Phase 4 (2023–2024, n=250): Gupta ring (n=55), Malyugin/microhooks (n=53), and capsule-guard low-flow hydrodissection (combined in final 108 cases). All cases used phacoemulsification some with torsional, settings depending upon the type and grade of cataract. Primary outcomes: successful pupil expansion, posterior capsule rupture (PCR), endothelial cell loss (ECL), final BCVA.
Results: Mean preoperative pupil diameter 3.1 ± 0.6 mm. Successful mechanical expansion achieved in 99.8% (1,140/1,142).
Compared with Phase 1, Phase 4 showed:
• Effective phaco time reduced 48% (1.7 vs 3.3 min)
• ECL reduced 56% (3.9% vs 8.8%) (both p<0.001)
• PCR declined from 2.8% to 0% (overall 0.9%; 10/1,142)
• Iris trauma requiring suturing 0.3% (3 cases, all Phases 1–2)
Final BCVA ≥20/40 in 96.4%. No case converted to extracapsular extraction.
Conclusion: Sequential transition from viscodilation and stretching → iris hooks → B-HEX → Gupta ring/Malugin ring devices transformed small-pupil phacoemulsification from high-risk to highly predictable, virtually eliminating posterior capsule rupture and severe iris complications in complex eyes. This large, real-world, long-term series provides a practical roadmap for managing difficult small pupils safely and efficiently.
