Ring Stretcher, High Power Manual Screw Ring Expander Finger Sizer Stick Adjust Ring Sizes 1-14

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personally I displace the compression ring gaps ~120° from the upper oil scraper ring's gap with this setup, but I doubt that it really matters much. Intraoperative further reduction in pupillary dilation likely related to prostaglandins release or iris touch with instruments,

Inadvertent placement of one haptic of intraocular lens (IOL) in the capsular bag and the other in sulcus which predisposes to iris chafing, inflammation after surgery, and concentration of the IOL after capsular healing This is a circular soft ring made of polyurethane which causes a circular dilation of the pupil to 6.3 mm. There are 4 outward projecting triangular portions with holes in each which help in positioning the device properly. The device may give a more circular appearance of postoperative pupil compared to the Malyugin ring. [19] Akman A, Yilmaz G, Oto S, Akova YA. Comparison of various pupil dilatation methods for phacoemulsification in eyes with a small pupil secondary to pseudoexfoliation. Ophthalmology. 2004;111(9):1693‐1698. doi:10.1016/j.ophtha.2004.02.008

The affordable cost is an important advantage of iris hooks. The hooks may be placed at the axis of intended toric IOL placement, thereby marking the axis. As the exposure at these areas is maximum, the toric marks of the IOL are easily seen. Putting an iris hook just behind the phaco wound avoids tenting up of iris in front of the phaco probe, reduces the chance of iris prolapse, and increases visibility. When 4 iris hooks are used at 90° to each other, a diamond or quadrangular opening or pupil is made and the surgical exposure can be excellent. With experience, the time needed for insertion and removal of the iris hook can be reduced considerably. WHAT DO YOU SUGGEST FOR ORIENTATION OF THE FIRST TWO RINGS And THEN THAT THIRD (bottom) OIL RING-especially how and where to to place the top and bottom rings OF THE OIL RING ASSEMBLY ( called "rails" at DEVES )see http: www.deves.com/oilring_inst.html The current version is called Malyugin ring 2.0 can be inserted through a 2 mm incision using a modified injector. Other modifications from the previous model include thinner material (5-0 polypropylene), wider coil gap, and more soft and elastic material. This model was released in 2016. Because of the thin profile, chances of damage to delicate ocular structures may be less. Also, the device typically does not hinder the surgical maneuvers, and inadvertent disengagement from the iris during surgery is very rare. Insertion and removal of this ring may be easier and faster than other options. [9] Two sizes are available 7 mm and 6.25 mm.

Graether 2000 pupil expander system (Eagle vision, Memphis, Tennessee, USA/Katena Products, Inc., Denville, New Jersey, USA) Chang DF. Use of Malyugin pupil expansion device for intraoperative floppy-iris syndrome: results in 30 consecutive cases. J Cataract Refract Surg. 2008;34(5):835‐841. doi:10.1016/j.jcrs.2008.01.026 Initial results of Bhattacharjee ring in 42 eyes showed that there was adequate dilation, no incidence of spontaneous device engagement, intraoperative hyphema in 2 eyes, iridodialysis in one eye, postoperative round pupils in all but 2 eyes, microscopic sphincter tear in 10 eyes, and iris chafing in 6 eyes. [29] Bhattacherjee ring has a very low vertical height of 0.1 mm which may offer an advantage in very shallow anterior chambers.

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Usually, 3-4 hooks are used via self-sealing peripheral corneal/limbal paracentesis (1.5mm) incisions leading to a triangular or square-shaped pupil. The pupil is stretched with another instrument (iris pusher) and then the pupillary margin is engaged in the hooks. The hooks are removed after the surgical procedure. Challenges with these hooks include increased surgical time and fluid loss through the incisions which may accumulate over the cornea in deep-seated eyes causing increased reflections and compromised visibility. Masket S. Avoiding complications associated with iris retractor use in small pupil cataract extraction. J Cataract Refract Surg. 1996;22(2):168‐171. doi:10.1016/s0886-3350(96)80213-6 The Haynes Manual @ pg.2-36 simply says to stagger the ring gaps around the Upper 180 degrees of each piston the the oil control ring gap facing up

Chakraborty D, Mohanta A, Bhaumik A. B-HEX pupil expander in vitreoretinal surgery - A case series. Indian J Ophthalmol. 2020;68(6):1188‐1191. DOI:10.4103/ijo.IJO_1675_19 A study [21] on 40 eyes noted that among iris hooks, Morcher ring, Beehler hooks, and pupil stretching; iris hooks, followed by Morcher ring had longest surgical times, though these achieved stable pupillary dilation throughout the surgery. Morcher ring caused the least iris trauma. Beehler pupil dilator and pupil stretching were associated with fast surgery. [21] The JT-RS151P is perfect for an accurate and easy stretching of all kinds of rings, including some types of stones. Before you stretch your ring, please make sure that you anneal it in advance to avoid unnecessary destruction. Push the lever until there’s some resistance. When you feel resistance, this is when you should be careful. Apply less pressure at this point. After using these hooks/methods, multiple sphincterotomies may be noted and the pupil may appear dilated. The pupil in such cases may be constricted intraoperatively using gentle centripetal strokes over iris with blunt instruments including Lester hook and intraoperative miotic agents (including pilocarpine). However, in most cases, the pupillary sphincter is not damaged till the full radial extent, and pupils retain a good cosmetic appearance and good pupillary response to light and accommodation. In the immediate postoperative period, miotic agents may be considered to prevent iridocapsular adhesion/synechia. In cases with severe iris manipulation, frequent topical steroids and close observation are must in the immediate postoperative period and oral/intravenous steroids may be added in a case-based approach. Muşat O, Mahdi L, Gheorghe A, et al. Inelul malyugin--alternativă în tratamentul pupilei "refractare" [Malyugin ring--an alternative in the treatment of a miotic pupil]. Oftalmologia. 2014;58(2):40‐42.

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Malyugin ring may offer easier and faster insertion and removal, and when carefully used iris trauma is minimal. [23] A study [9] on 30 eyes using Malyugin ring noted minor hyphema in 1 eye, spontaneous disengagement of the device in 1 eye (one scroll was not engaged properly to the iris during its positioning), minor sphincter tears visible in slit-lamp in 5 eyes (pupil was round and reactive), iris chafing and transillumination defect in 8 eyes, and high intraocular pressure in 3 eyes. Other challenges noted in the study included temporary deformation of the device during loading or injection which might have been related to insufficient cooling (immediate use within 5 minutes of flash sterilization). Entanglement of the side scrolls was noted in one case, which needed removal of the device and insertion of a new one. [9] Bhattacharjee S. B-HEX pupil expander: Pupil expansion redefined. Indian J Ophthalmol. 2017;65(12):1407‐1410. DOI:10.4103/ijo.IJO_673_17