Intraoperative and Postoperative Management for a Small Eye With Secondary IOL Implantation

Published on September 8, 2026 by Dr Muhammad Azeem with the help of AI which helped him organise his thoughts

This case continues the planning for cataract surgery in a small, susceptible eye, with a focus on what happens during and after the operation: fluid pressure, pupil control, and how inflammation is managed afterward.

1. IV Mannitol

   IV mannitol may be considered intraoperatively to reduce intraocular pressure and positive vitreous pressure.

2. IOL Configuration and Postoperative Vault

   Pay particular attention to the intended IOL position and postoperative vault. An abnormal or unexpected haptic configuration may produce an undesirable vaulting relationship. The IOL should be positioned in the configuration intended for the selected fixation site and IOL model, with careful confirmation of centration and stability.

3. Keep the Pupil Mobile

   Cycloplegic or mydriatic treatment, such as cyclopentolate or tropicamide when clinically appropriate, may help maintain pupillary mobility. The objective is to reduce iris crowding and the risk of posterior synechiae while maintaining adequate visualization and surgical control. Pharmacologic dilation should be individualized, because the risk of angle closure can be significant in nanophthalmos.

4. Prophylactic Peripheral Iridectomy / Iridotomy

   In highly susceptible small eyes, prophylactic peripheral iridectomy or iridotomy should be strongly considered when the anatomy and surgical plan indicate a meaningful risk of pupillary block. The decision should be individualized rather than treated as an automatic requirement for every short eye.

5. Anaesthetic and Intraoperative Pressure Planning

   These eyes may benefit from meticulous anaesthetic and intraoperative planning to minimize positive vitreous pressure. The choice between local/regional and general anaesthesia should be individualized with the anaesthesia and surgical teams. The anaesthetist should be advised to hyperventilate the patient, as these eyes often have thickened choroids.

6. Postoperative Steroid Strategy

   Continue topical corticosteroid therapy for an appropriately prolonged period when postoperative inflammation is substantial, with tapering guided by the clinical response. Avoid an unnecessarily abrupt taper in eyes with persistent inflammation, while monitoring intraocular pressure and other steroid-related adverse effects.

7. If Oral Steroids Are Not Tolerated

   If systemic corticosteroids are poorly tolerated or contraindicated, involve an internist or rheumatologist when systemic anti-inflammatory therapy is clinically necessary. Alternative systemic treatment, including disease-modifying antirheumatic drugs (DMARDs) in appropriate inflammatory disorders, should only be considered under relevant specialist supervision and for a defined indication.