A Study of Visual Outcome and Management of Small Pupil in Cataract Surgery

A BSTRACT Introduction: Cataract surgery in patients with small pupils presents significant challenges and potential complications. This study aimed to evaluate visual outcomes and effectiveness of various management strategies for small pupils during manual small incision cataract surgery (MSICS). Methods: This interventional study, conducted at a tertiary care center in Maharashtra, included 95 patients with pupils less than 5 mm in diameter undergoing MSICS between March 2023 and March 2025. Various management strategies were employed including pharmacological methods (intracameral phenocaine and adrenaline), mechanical dilation (stretch pupilloplasty and sphincterotomy), and expansion devices (iris hooks, BHEX ring). All surgeries were performed by a single surgeon. Patients were followed up on postoperative days 1, 3, 7, 21, and 6 weeks. Visual outcomes and complications were documented and analyzed. Results: The majority of patients (71.6%) were aged 61–80 years with nearly equal gender distribution. Diabetes mellitus (31.6%), pseudoexfoliation syndrome (18.9%), and posterior synechiae (7.4%) were the main causes of small pupils. Intracameral phenocaine was the most frequently used management strategy (38.9%). Posterior capsule rent was the most common intraoperative complication (5.3%), while 24.2% of surgeries had no complications. By 6 weeks postoperatively, 89.4% of patients achieved vision of 6/24 or better. There was no statistically significant difference in visual outcomes among different management techniques ( P > 0.05). Conclusion: Small pupils in cataract surgery require a tailored approach based on the underlying etiology. With appropriate preoperative assessment and management strategy selection, good visual outcomes can be achieved regardless of the specific technique used. These findings have significant implications for resource-limited settings, suggesting that simpler techniques can achieve results comparable to more complex devices in appropriately selected cases.