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Surgical TechniqueB-HEX Pupil ExpanderPupil expansion redefined

Bhattacharjee, Suven

Author InformationIndian Journal of Ophthalmology 65(12):p 1407-1410, December 2017. | DOI: 10.4103/ijo.IJO_673_17

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Abstract

The B-HEX^® Pupil Expander (Med Invent Devices) is a disposable 6.5 mm flexible hexagonal device with notches at corners and flanges at sides. Alternate flanges with positioning holes are tucked under the iris to engage the notches to the margin of the pupil to provide a 5.5 mm expanded pupil. Unlike devices with scrolls or pockets which require an injector to avoid snagging the incision, the preloaded B-HEX is inserted and removed through a 1 mm or larger incision using a manipulator or 23-gauge micro-forceps. The thin profile and uniplanar design allow unhindered instrument movement during phacoemulsification, cortical cleaning, and intraocular lens implantation. The B-HEX is safely used even after capsulorhexis since the thin uniplanar notches are directly visualized to avoid the capsule margin. It is useful in coaxial phacoemulsification, coaxial sub 2.00 mm micro incision cataract surgery (MICS), biaxial 1.5 mm MICS, femtosecond laser assisted cataract surgery (FLACS), small pupil pars plana vitrectomy, and shallow anterior chamber eyes.

Phacoemulsification in small pupil eyes is challenging due to reduced workspace and limited visibility. Intraoperative floppy iris syndrome (IFIS) often poses additional challenges. Eyes with preoperative dilated pupil of 7.0 mm or smaller are at risk for IFIS regardless of systemic α-1 adrenergic receptor antagonists treatment.[¹] Mechanical devices achieve a consistently large pupil diameter that will not constrict regardless of the IFIS severity or the type of viscosurgical device or fluidic parameters used.[²] To deliver good outcomes, a surgeon should be conversant with the use of pupil expansion devices. This paper presents techniques for a pupil expander which employs a radically different principle from that of existing devices.

The B-Hex^® Pupil Expander (Bhattacharjee Ring)

The B-HEX^® Pupil Expander [Fig. 1] (Med Invent Devices, Kolkata, India), a third generation Bhattacharjee Ring,[³] is a flexible jointless hexagonal plastic (Polyimide) ring with a 0.075 mm profile having notches and flanges disposed in a single plane. Each disposable 6.5 mm B-HEX provides a 5.5 mm expanded pupil. It is preloaded in a transparent single-use carrier with an ergonomic handle which delivers the device sterile at the incision. The device is inserted, engaged to the pupil margin, and removed using a dull tip micro Sinskey hook manipulator provided in the pack. However, a 23-gauge DSEK forceps provides greater control and speed in all these maneuvers. The flexible notches allow maneuvrability while resilient flanges resist buckling under the compressive force of the nondilating pupil. It is ethylene oxide sterilized and intended for single use. Autoclaving or reuse alters the shape and flexibility affecting performance. Removing the device from the carrier may damage it or render it unsterile.