Guest Cataract Surgery: Tiny Pupil with Synechiae

This patient had a prior uveitic episode which resulted in the formation of posterior synechiae, where the iris, at the pupil margin, is adherent to the anterior lens capsule. As a result, despite multiple topical medications, the pupil was unable to be dilated pharmacologically. In this case, guest surgeon Brian Lee MD shows his technique of releasing the synechiae and then expanding the pupil with iris hooks.

There are important teaching points in this video:

  • The synechiae can be mechanically broken with a blunt instrument such as a 27g cannula from the viscoelastic syringe or a spatula.
  • While we need to have some visoelastic to keep the anterior chamber formed, avoiding injecting too much of it under the iris. A small amount can elevate the pupil margin and facilitate placement of the iris hooks.
  • When making the small limbal incisions for the iris hooks, aim them down towards the pupil margin so that the iris hooks have the correct angle
  • Pull the iris using the hooks only half-way initially, until all four hooks are placed. Then you can go back and tighten them more to further expand the pupil.
  • To remove the hooks there is a short-cut method that works well for flexible hooks: just give them a quick tug and they will release the iris and come right out of the eye.

Click below to learn from this case and feel free to submit a case of your own:


  1. Doctor Devgan, thank you for your work!
    I’m from smal town in Russia, and your video is the only opportunity to improve my surgery skills

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