Optimizing Small-Pupil Phacoemulsification: A 12-Year Single-Surgeon Evolution In 1,142 High-Risk Eyes

To evaluate long-term outcomes and complication trends associated with the sequential adoption of pupil-expansion strategies in high-risk small-pupil cataract surgery over a 12-year period.

Retrospective analysis of consecutive small-pupil cataract surgeries performed by a single surgeon at a tertiary eye care centre in India over a 12-year period, encompassing a broad spectrum of high-risk clinical scenarios.

A retrospective consecutive series of 1,142 eyes with pharmacologically dilated pupil diameter ≤4.0 mm undergoing phacoemulsification by a single surgeon (2012–2024). High-risk features included pseudoexfoliation (38%), intraoperative floppy iris syndrome (18%), chronic miotic use (18%), uveitic synechiae (14%), and prior acute angle-closure (12%).

Surgical strategies evolved sequentially: Phase 1—viscodilation with bimanual stretching (n=360); Phase 2—iris retractors (n=180); Phase 3—B-HEX pupil expansion ring (n=352); Phase 4—Gupta ring, Malyugin ring/microhooks, and low-flow capsule-guarded hydrodissection (n=250).

Primary outcomes were pupil expansion success, PCR, ECL, and final BCVA.

Mean preoperative pupil diameter was 3.1 ± 0.6 mm. Successful mechanical pupil expansion was achieved in 99.8% of eyes (1,140/1,142).

Compared with Phase 1, Phase 4 demonstrated:
• 48% reduction in effective phaco time (1.7 vs 3.3 minutes)
• 56% reduction in ECL (3.9% vs 8.8%; p<0.001)
• PCR reduction from 2.8% to 0% (overall PCR 0.9%; 10/1,142)

Iris trauma requiring suturing occurred in 0.3% (3 eyes), confined to Phases 1–2. Final BCVA ≥20/40 was achieved in 96.4%. No case required conversion to extracapsular extraction.

A structured transition from viscodilation and mechanical stretching to contemporary pupil-expansion devices transformed small-pupil phacoemulsification from a high-risk procedure into a highly predictable and safe surgery. This large, long-term real-world series provides a practical roadmap for minimizing complications and optimizing outcomes in complex small-pupil cataract cases.