Archive April 2017 XVIII, No. 4

Your Options for Managing Small Pupils

The list of devices and drugs for pupillary dilation and maintenance is growing.

Jim Burger

Jim Burger, Senior Editor


narrow pupil SMALL CHALLENGE Surgeons can call on a widening variety of devices to deal with stubbornly narrow pupils.

What do cooks, woodworkers and cataract surgeons have in common? They all do better when they have lots of working space. Inadequate pupillary dilation occurs only in a small percentage of patients, but when it happens, it's important to have a solution at the ready. Fortunately, surgeons and surgery facilities have more mechanical and pharmaceutical options than ever. Here's a review.

Mechanical devices
Along with the traditional iris hooks, a growing number of ring-type devices are now available, promising greater efficiency and ease of use and low trauma to the iris.

All of the rings are effective, says T. Hunter Newsom, MD, founder of the Newsom Eye & Laser Center in Tampa, Fla. "The good news is that we have several different options that doctors can play with and see which fits well with their practice technique," he says. And, he adds, since companies with newer options are looking to get a foothold, they're usually happy to provide samples.

What factors are likely to affect buying decisions? Cost is a consideration, of course. Some rings are disposable, while some may be used up to 5 times. Some come attached to inserters, some require separate injectors that need to be sterilized between uses. Some are square, some provide a more circular space. For Dr. Newsom, the most important consideration is how easy it is to get the ring into the eye and back out again.

"Surgeons have different techniques, different likes and dislikes," he says. "The big thing is to try several different ones. The one that works best is the one that fits with your technique."

Malyugin Ring The updated Malyugin Ring is softer and can be inserted through smaller incisions.

Some options to consider:
Malyugin Ring 2.0 (MicroSurgical Technology). The popular ring has 8 points of fixation, with a goal of ensuring a round pupil (6.25 mm and 7 mm sizes are available), and reducing the risk of damage to the iris. Last year, the company released an updated version that's softer and more elastic, and can be inserted through smaller (1.8 to 2 mm) incisions. The smaller size is also intended to address inadequate pupil size during femtosecond laser cataract surgery. Like its predecessor, the ring looks like a baseball diamond with a loop at each corner. It's disposable and comes with newly designed disposable injectors that are easier to engage and disengage. The Osher Malyugin Ring Manipulator is reusable, however.

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