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46 | EYEWORLD | MAY 2020 by Maxine Lipner Senior Contributing Writer SKILL FOCUS ATARACT C Thomas Oetting, MD, relies on pupil expansion devices when a patient is on an alpha blocker or has a past history of uveitis. If the pupil is small because drops weren't given in time, he said he may proceed with the aid of some epinephrine and insert a device later, if needed. Considering pupil devices When deciding between pupil expansion devic- es or iris hooks, Dr. Oetting considers other hardware he might need inside the eye, such as a capsular tension segment or an especially big lens. "I think iris hooks are good if you want to be 100% sure there's no prolapse," Dr. Oetting said, adding that for most patients with a reasonable chamber depth, he finds it quicker to use a Malyugin ring. Dr. Koch uses a pupil expansion ring if the iris is not fibrotic. "Whenever I see the pupil is too small and I need to enlarge it to 6 mm and I don't see a lot of fibrosis, I use the Malyugin ring," Dr. Koch said. However, he avoids these H ooks and expansion rings can be an ophthalmologist's partner when performing phacoemulsification. Douglas Koch, MD, relies on pupillary expansion devices when there's a risk of inadequate visualiza- tion or the potential for iris trauma (via accidental engagement with the phaco tip or through some other manipulation). "When I'm doing phacoemulsification, if the iris is not particularly floppy, I'm comfortable working through pupils as small as 4 mm," Dr. Koch said. "When I'm doing an IOL exchange, I may need to visualize the haptics and their location in the capsular fornix. That requires a pupil size that's 8 mm or larger, so I may need to use iris hooks in the area of the haptics in order to get visualization for that." In the case of a subluxated lens and cap- sule, Dr. Koch usually performs scleral fixation of the IOL and capsule. With this procedure, it's important to see where the haptics are, which may mean enlarging the pupil to 7 mm. Placing hooks, rings, and things About the doctors Douglas Koch, MD Professor and Allen, Mosbacher, and Law Chair in Ophthalmology Cullen Eye Institute Baylor College of Medicine Houston, Texas Thomas Oetting, MD Professor of ophthalmology University of Iowa Iowa City, Iowa Experience EyeWorld 24/7 EyeWorld.org Supplements Recent articles in web-friendly format Searchable archives from 2007 to present EyeWorld Weekly news feed Trending videos Live Twi•er feed