Femtosecond laser-assisted cataract surgery (FLACS) entered the ophthalmic field around 8 years ago, and in doing so, it helped advance the safety and predictability of cataract surgery. However, every physician knows that while new technologies help address existing problems, they can also create new challenges.
In the case of FLACS, operating on eyes with a small pupil size is that challenge. Indeed, the procedure is contraindicated in eyes with pupil diameters smaller than 5 mm in order to minimise the risk of hitting the pupillary edge during capsulotomy or creating an insufficiently sized capsulorhexis.1,2
A further challenge posed during FLACS is the occurrence of intraoperative miosis secondary to prostaglandin release into the aqueous humour. As such, even eyes with adequate preoperative pupil sizes carry the risk of becoming problematic during surgery.
Fortunately, cataract surgeons have a variety of options for expanding small pupils, including iris retractor hooks and intracameral injection of adrenergic receptor agonists. However, in some patients, these conventional expansion strategies are ineffective, unpredictable or unsafe. And when miosis occurs intraoperatively—a phenomenon that literature shows can occur in up to 30% of eyes undergoing FLACS—options become even more limited.3-5