Title Management Of Small Pupil During Phacoemulsification: Clinical Role Of Bimanual Pupil Stretching Case Series

To evaluate pharmacological and mechanical methods of pupil expansion during phacoemulsification, with particular emphasis on the effectiveness, safety, and clinical applicability of bimanual pupil stretching (BPS).

A literature review and clinical experience analysis were performed in patients with small or poorly dilating pupils undergoing phacoemulsification. Causes included pseudoexfoliation, synechiae, glaucoma, IFIS, miotic therapy, and prior surgery. Pupil management was pharmacological or mechanical. Outcomes included pupil diameter, stability, surgical time, and postoperative appearance.

Results:

Pharmacological dilation alone was frequently insufficient in eyes with rigid or fibrotic pupils. Viscodilation provided temporary pupil enlargement but often resulted in unstable dilation requiring repeated application. Mechanical expansion techniques achieved more reliable and stable pupil enlargement. The largest pupil diameters (approximately 6.25–7.0 mm) were obtained using pupil expansion devices; however, these required additional surgical time, specialized instrumentation, and increased costs.

Bimanual pupil stretching achieved mean pupil diameters of approximately 5.5–5.9 mm, sufficient for safe phacoemulsification in most cases. BPS was among the fastest pupil expansion techniques and did not significantly prolong surgical time. When performed carefully, postoperative pupil appearance was comparable to that achieved with pupil expansion rings.

Conclusion:

Small pupil remains a common and clinically relevant challenge in cataract surgery. A stepwise and individualized approach to pupil management is essential. Bimanual pupil stretching is a simple, fast, cost-effective, and widely available technique that provides adequate pupil enlargement for safe phacoemulsification in selected cases without the need for additional devices.