A case of dense nuclear cataract has undergone phacoemulsificaton by horizontal chop technique. the pupil was small so Iris retractor was utilized. Intraocular lens was implanted.

1. Cataract Surgery
Difficult Cases: Small Pupil
Surgeon: Dr Joobin Khadamy
Vali-E-Asr Hospital, Birjand
Birjand University of Medical Science
BIUMS- 2017

2. Dr. Joobin Khadamy 2

3. 1. Anesthesia: Topical Anesthesia
2. Prep & Drape : Betadine 10%
3. Eyelid Speculum insertion
4. Washing Ocular Surface and Fornixes
Dr. Joobin Khadamy

4. Dr. Joobin Khadamy

5. Stab at 15° knife at 7 & 11 clock
• Tips: use cotton tip applicator to fix eye, it
could be placed the counter side or even just
posterior to insertion side
– Note 1: the cutting edge of knife should be opposite
to surgeon side.
– Note 2: the tip of knife should head toward center
of eye and follow its radius.
– Note 3: follow a plane parallel to iris plane.
Dr. Joobin Khadamy

6. Dr. Joobin Khadamy

7. Small Pupil Managment
Intracameral
injections
Ocular
viscoelastic
devices (OVD)
Mechanical
devices
Dr. Joobin Khadamy

8. Dr. Joobin Khadamy

9. Epinephrine
• 1:4000
Trypan blue
•Use before OVD
•Irrigate the dye: Epinephrine
•Atropin: Not certified
OVD
• Highly cohesive
Dr. Joobin Khadamy

10. Dr. Joobin Khadamy

11. Iris Retractors
• Four short and narrow incisions
– At limbus
– Clock 2, 4, 8 & 10
• Notice: thereafter first retractor placement,
insert the second adjacent to previous one;
not at counter site.
Dr. Joobin Khadamy

12. Dr. Joobin Khadamy

13. Capsulorhexis
•Bented cystome
•Large rhexis
Dr. Joobin Khadamy

14. Dr. Joobin Khadamy

15. Hydrodisection
•Nucleus rotation
Phaco
emulsification
• Chop technique
• Intracapsular
fragmentation
I&A
• Cortical material
removal
Dr. Joobin Khadamy

16. Dr. Joobin Khadamy

17. OVD
•Forming capsular bag
IOL
• Implantation in bag
I&A
• OVD removal
Dr. Joobin Khadamy

18. Dr. Joobin Khadamy

19. Forming
A/C
Stromal
hydration
Retractor
removal
Dr. Joobin Khadamy

20. Dr. Joobin Khadamy

21. Thanks
• Mr. M Ahmadi
• Mr. Kiani
• Mrs. Masoumi
• Mr. Sabzali
• Mr. Nabayee
• …….
Dr. Joobin Khadamy