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There are a number of tools available for mechanical dilation of small pupils, including iris hooks and intraocular rings. The APX 200 Pupil Expanding Device (APX Ophthalmology) is a new pupillary expansion device that can achieve a large square or trapezoidal opening with minimal intraocular manipulation. The device resembles miniature scissors with blunt, c-shaped claw ends that are kept open via reverse spring action. A specialized forceps is used to close the device during insertion, positioning, and removal. The APX 200 Pupil Expanding Device is disposable.
The APX expander device is placed through a 19G stab incision. The terminal end goes under the iris and stretches it nicely; the procedure is repeated on the opposite side. The pupil is large and I find that I can perform the capsulorhexis, phacoemulsification, and IOL insertion without having to adjust the location of the APX expanders. I have also used the APX expanders in conjunction with intraoperative abberometry (ORA System, Alcon Surgical) and found that the expanders do not induce astigmatism. You may leave them in throughout the whole case.
To remove the device, you engage the distal end, which is exterior to the eye, with the specialized forceps and retract through the small stab incisions. I find the APX to be gentle on the iris, leaving the iris looking as though it had not been stretched.