I-Ring offers new strategy for intraoperative small pupil management

Adequate visualization of the cataractous lens is essential for safe phacoemulsification and IOL implantation. A compromised lens view due to partial iris coverage, in cases of a pupil smaller than 5 mm, can pose several challenges to the cataract surgeon and result in potential intraoperative complications including iris tissue damage with secondary bleeding and miosis, pupillary sphincter tear, posterior capsular tear, dropped nucleus, and vitreous loss with possible secondary retinal complications. Surgical difficulty with a small pupil can be further compounded by the presence of zonular weakness, capsular inadequacy, a shallow anterior chamber and a brunescent complete cataract. Further, normal iris resting position in a well-dilated state is usually optimal for safe phacoemulsification.When the iris tissue is floppy, it escalates the difficulty of modern-day cataract surgery. To optimize pupillary size and manage floppy iris tissue, in addition to ophthalmic viscosurgical devices, various pharmacological agents may be used preoperatively. These include parasympathetic antagonists such as tropicamide 0.5%, cyclopentolate 1% or 2%, and homatropine 2% or 5%; sympathetic agonists such as phenylephrine hydrochloride 2.5% or 10%; along with possible intraoperative use of bisulfate-free epinephrine, intraocular lidocaine, lidocaine plus epinephrine, intracameral phenylephrine 1.5%, or phenylephrine plus lidocaine.