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Bhattacharjee Rings require only a single 0.9 mm (20G) incision for Pupil expansion

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Session Details

Session Title: Cat Surgery Equip/Phaco

Session Date/Time: Monday 15/09/2014 | 14:30-16:00

Paper Time: 15:36

Venue: Boulevard F (Level 1)

First Author: : S.Bhattacharjee INDIA

Co Author(s): :                  

Abstract Details


To determine the smallest size and least number of incisions required, pupil expanding efficacy, stability and safety of the Bhattacharjee pupil expansion rings.


Nayan Eye Associates, Kolkata, INDIA.


Square (BSQ) and hexagon (BHX) designs of the disposable Bhattacharjee pupil expansion rings made of 5-0 Nylon, have notches at the corners and flanges at the sides, have a joint and are entirely disposed in a single 0.1 mm thin plane. The white to white corneal diameter (WTW) was used to choose the size. In the first phase, for insertion, a stepped reduction in incision size from 2.2 to 0.9 mm was followed and all eyes underwent 2.2 mm coaxial phacoemulsification. In the second phase, initially two and then a single 0.9 mm side port incision was used to insert and engage the device to the pupil. The device was used in 1.4 mm bimanual MICS, intraoperative miosis and shallow anterior chambers. Insertion, placement, ease of instrumentation, stability, intraoperative complications, and removal of the devices were recorded. Enlarged pupil size and capsulorhexis size were measured. Intraoperative complications such as hyphema, posterior capsule tears, vitreous loss and sphincter tears were recorded. IFIS severity was graded after removal of the device and during viscoelastic removal. Pupil size, shape, gross and microscopic sphincter tears, anterior iris surface depigmentation, stromal atrophy, transillumination defects and endothelial cell counts were recorded during postoperative examination.


Bhattacharjee rings were used in 64 eyes of 55 patients. Average preoperative dilated pupil was 4.3 mm. Average enlarged pupil size was 5.2 mm with BSQ6.5, 5.7 mm with BSQ7.0, 5.0 mm with BHX6.0 and 6.0mm with BHX7.0 models. Average capsulorhexis size was 4.9 mm. In 42 eyes a 0.9 - 2.2 mm incision was used for insertion of the ring in addition to two 0.9 mm side ports. Two 0.9 mm incisions were used to insert the device and engage it to the pupil margin in 15 eyes. In 5 of these eyes the incisions were enlarged to 1.4 mm for bimanual MICS. Only a single 0.9 mm incision was used for insertion and pupil expansion in 5 eyes. The rings were used in two eyes with intraoperative miosis and in two eyes with central anterior chamber depth of 1.72 mm and 1.91 mm. There was no snagging of the incision and the device remained stable providing adequate pupil expansion for phacoemulsification. The device maintained shape and integrity during the surgery. No significant intraoperative or postoperative complications were noted. Pupil shape and function were retained. The anterior flanges restricted billowing of the iris and IFIS related complications were reduced.


Pupil expansion devices like the Malyugin ring, which require a 2.2 mm or larger incision and have a biplanar structure at the corners, are either unsuitable for or are a compromise in Femtosecond laser-assisted cataract surgery (FLACS), micro incision cataract surgery (MICS), small pupil pars plana vitrectomy (PPV - MIVS) and shallow anterior chambers. The Bhattacharjee rings can expand the pupil effectively and safely using a single 0.9 mm (20G) incision. This and the thin profile make the device suitable for Femtosecond laser-assisted cataract surgery, bimanual and coaxial MICS, standard and micro coaxial phacoemulsification, intraoperative miosis, small pupil PPV and eyes with shallow anterior chamber. The anterior flanges of the rings appear to restrict iris billowing and can reduce IFIS related complications. The hexagon provides greater pupil expansion compared to a same sized square. The WTW corneal diameter is easily measurable and should be the primary criteria to choose the size of any pupil expansion ring. The amount of pupil expansion the surgeon desires should be secondary. Iris sphincter tears were rare in eyes with IFIS because of the elastic nature of the pupil margin. Sphincter tears are probably a reflection of the rigidity of the pupil and not necessarily an indicator of the trauma caused to the pupil margin by a pupil expansion device. The Bhattacharjee rings being made of Nylon do not float in BSS and do not have the risk of floating and touching the endothelium when disengaged unlike a device which is made of Polypropylene. Unlike Caucasian eyes which show iris transillumination defects, in Asian eyes, anterior iris surface depigmentation and stromal atrophy provide a better reflection of iris trauma. Because of the simple design the Bhattacharjee ring may be machine made as a truly continuous ring with no joint and this could reduce costs significantly.

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