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Pupil Management During Phacoemulsification in Patients with Iridoschisis

Castanera, Jorge MDa

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Journal of Cataract & Refractive Surgery: June 2001 - Volume 27 - Issue 6 - p 797
doi: 10.1016/S0886-3350(01)00918-X
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In the September issue, Smith and Liu1 report the use of iris hooks to prevent iris damage during phacoemulsification in a case of iridoschisis. I had the opportunity to treat a similar case that had more extensive iridoschisis extending from 2:30 to 9:30 (Figure 1). In this case, the use of iris hooks would have been difficult; it would have required too many paracenteses, and some of the hooks would have interfered with the temporal clear corneal incision I use.

Figure 1.
Figure 1.:
(Castanera) Intraoperative video image shows the iridoschisis and small pupil.

Instead, I used a Graether pupil expander. This is a silicone ring with an inner diameter of 7.00 mm when fully expanded and a grooved outer profile that engages the iris sphincter in all its circumference except for a 3.75 mm gap (Figure 2).2 Once in place, the pupil is fully dilated and all the fibrillar material is kept out of the way of the phaco tip (Figures 3 and 4), allowing for almost routine surgery. At the end of phacoemulsification, the capsulorhexis is clearly seen (Figure 5), allowing easy insertion of an intraocular lens (IOL).

Figure 2.
Figure 2.:
(Castanera) Schematic view of the Graether pupil expander.
Figure 3.
Figure 3.:
(Castanera) The pupil expander is in place, showing a dilated and regular pupil.
Figure 4.
Figure 4.:
(Castanera) The phaco-crack technique is performed through a temporal clear corneal incision.
Figure 5.
Figure 5.:
(Castanera) The final appearance of the eye before the IOL is inserted.

In my opinion, the Graether pupil expander offers some advantages over iris hooks in cases of iridoschisis:

  1. The pupil is widely and uniformly dilated, avoiding focal stretches that often induce sphincter ruptures.
  2. The sphincter is engaged around almost all the cir- cumference, a useful technique regardless of the extension of the iridoschisis.
  3. There is no need to perform a limbal groove or multiple paracenteses.
  4. Retractors outside the eye during surgery are avoided; these can interfere with some maneuvers, especially in the phaco-crack technique.

Jorge Castanera MD

aBarcelona, Spain


1. Smith GT, Liu CSC. Flexible iris hooks for phacoemulsification in patients with iridoschisis. J Cataract Refract Surg 2000; 26:1277-1280
2. Graether JM. Graether pupil expander for managing the small pupil during surgery. J Cataract Refract Surg 1996; 22:530-535
© 2001 by Lippincott Williams & Wilkins, Inc.