3 tricks for Small Pupil + Flomax Cataract Surgery without Expanders or Iris Hooks

3 tricks


Can you do cataract surgery in an eye with a small pupil without having to use expanders or iris hooks? Yes, most certainly and you can produce a beautiful result with less iris trauma and without causing corectopia. Here are three tricks that can help you learn this technique:


Trick 1: Stretch the pupil and visco-dilate

Use two choppers or other instruments to engage the pupil margin at two points, 180 degrees apart. Then stretch the pupil all the way to the angle of the eye. Now use your viscoleastic to further expand the pupil and keep it that way to make plenty of room for your capsulorhexis.

Trick 2: Make the capsulorhexis larger than the pupil

You do not need to directly visualize the edge of the capsulorhexis to know where it is. If you can get the pupil to 4 mm in diameter with stretching and visco-mydriasis, then you can make a 5 or 5.5 mm diameter capsulorhexis. Have faith and make the capsulorhexis larger than the pupil.

Trick 3: Bring the nucleus out of the capsular bag

Using careful and slow hydro-dissection, bring the cataract nucleus partially out of the capsular bag and into the iris plane. The pupil will now help to hold the nucleus in place as you chop it and use the phaco probe to emulsify it.

One final tip:

After IOL insertion but before removal of the viscoelastic, use the chopper to tent the iris up 360 degrees to see if any residual cortex or nuclear chips are still remaining. You can also verify that the IOL optic is behind the capsulorhexis and in proper position.

pupil stretching
After pupil stretching during cataract surgery, the iris returns to its baseline. The photo on the right is 1 day after the cataract surgery which shows a good cosmetic and functional result.

Watch the video below to learn these techniques:



  1. Good tips sir ,
    In my opinion while stretching pupil , Y shaped dialor for pushing and C of J shaped for pulling pupil will make this step easy and efficient .
    Need your guidance on this.

  2. Have noticed that pupil stretching in PSX cases rarely achieves adequate pupil size for safe phaco.

    1. thank you for the insight of your experience. It depends on the patient and the surgeon. As you can see from the video below, pupil stretching was enough to finish this surgery very well.

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