Mastering Manual Pupil Stretching
For a resident surgeon, manual pupil stretching is a reliable, cost-effective technique to manage miosis and improve visualization. The basic steps involve using two instruments, typically a hook and a second-hand manipulator (like a chopper or push-pull), to grasp the iris margin at opposite poles. Slowly and steadily pull the instruments apart toward the limbus, holding the stretch for a few seconds to allow the sphincter muscle to undergo plastic deformation. Repeat this maneuver in a perpendicular direction to create a roughly square or diamond-shaped opening. Causing some micro-sphincter tears with tiny droplets of blood at the pupil margin is normal and expected.
This technique is excellent for most standard miotic pupils, providing a quick increase in the surgical field without the need for expensive expansion devices. However, you may want to avoid this technique in eyes with intra-operative floppy iris syndrome (IFIS). In these cases, the iris lacks structural rigidity and stretching often fails to maintain a larger aperture and can actually exacerbate prolapse and iris billowing. For IFIS, iris hooks or expansion rings may be more helpful for ensuring a stable pupillary diameter.
