This is a tough case in a patient with prior synechiae, a small pupil, a shallow anterior chamber, and a delicate iris. The biggest challenges are the shallow AC (how much space do you need to insert a pupil ring?) and also the delicate, pale blue iris. An iris that is completely lacking pigment (like in this patient) means that the iris stroma is thin and delicate. Any manipulation, even gently placing a Malyugin pupil expansion ring, is likely to cause some iris transillumation defects. And if you’re not careful, you can get iatrogenic iris damage that can cause an ugly cosmetic deformity. Our guest surgeon does a great job of handling this tough case — so many great pearls to learn.
How would you have done the case, I think pupil stretch would also cause damage, how about iris hooks?