Chicago—Eyes with small pupils create challenges for cataract surgery and are at increased risk for intraoperative complications.

During the Spotlight on Cataract session at AAO 2016, Thomas A. Oetting, MD, MS, shared five pearls for operating in eyes with small pupils. In the follow-up discussion, panel members commented on their experiences with newer options for small pupil management.

Dr. Oetting’s first tip addressed the use of iris hooks, and he recommended that the incisions for their placement be made very posterior and very flat.

In a video, Dr. Oetting demonstrated using a 26-gauge bent needle to create the incisions without the use of viscoelastic. He noted that he places the hooks in a diamond configuration with the main incision over one of the hooks.

“This approach makes iris prolapse nearly impossible,” said Dr. Oetting, clinical professor of ophthalmology and visual sciences, University of Iowa.

For his second tip, Dr. Oetting reminded surgeons that 6.5 mm is greater than 6.25 mm. The obvious statement related to a case where he wound up implanting an IOL with a 6.5-mm optic after placing a 6.25-mm Malyugin Ring (MicroSurgical Technologies). His intraoperative video showed how the lens became entangled in the pupil stretching ring.