Purpose To compare 4 methods for intraoperative pupil dilatation in eyes with pseudoexfoliation syndrome and insufficient pupil size during phacoemulsificatio n. Design Prospective, randomized, comparative, interventional case series. Part icipants Forty eyes of 40 patients with pseudoexfoliation and maximally dilated pupil size smaller than 3.5 mm. Intervention Mechanical pupil dilatation with ir is-retractor hooks (group I), polymethyl methacrylate (PMMA) pupil dilator-rin g (Morcher, Stuttgart, Germany) (group II),Beehler pupil dilator (group III), an d bimanual stretching (group IV). Main outcome measures Performance (pupil size achieved), complications, and added surgical time. Results The mean pupil sizes achieved with the PMMA pupil-dilator ring, Beehler pupil dilator, and bimanual stretching were 5.9±0.6 mm, 5.5±0.8 mm, and 4.9±0.7 mm, respectively. A squar e-shaped pupil was achieved with iris-retractor hooks, and the mean size of th e largest circle that can fit in this square was 5.6±0.6mm. There were no stati stically significant differences in the postdilatation pupil sizes between the 4 study groups (P >0.05). Apart from self-limited intraoperative hemorrhage from pupil margin, iris sphincter rupture was the only observed complication related to mechanical pupil dilatation. This occurred in 4 eyes in groups I and III, 3 eyes in group IV, and 1 eye in group II (P >0.05). The mean added surgical time for placement of iris-retractor hooks and for implantation of a PMMA pupil-dil ator ring was 297±51 and 176±54 seconds, respectively. The additional time req uired for pupil dilatation with the Beehler pupil dilator and bimanual stretchin g was 65±8 and 55±10 seconds, respectively. The time needed for pupil dilatati on in groups I and II is significantly longer than that in groups III and IV(P< 0.001). Conclusions All 4 methods used in this study were effective procedures f or the mechanical dilatation of small pupils secondary to pseudoexfoliation synd rome. Iris-retractor hooks and the PMMA pupil dilator ring are the most time co nsuming techniques but have the advantage of a stable pupil size throughout the surgery. The PMMA pupil dilator ring causes the least iris trauma. The Beehler p upil dilator and bimanual stretching technique were the least time consuming met hods for mechanical pupil dilatation.
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