Eyeworld

16 | EYEWORLD | APRIL 2020 ASCRS NEWS Intraocular epinephrine is an off-label but inex- pensive method for surgical mydriasis. I invited the Wills residents to review this study on the efficacy and cost effectiveness of intracameral epinephrine that appears in the April JCRS issue. —David F. Chang, MD EyeWorld Journal Club Editor Tara Uhler, MD Director of the ophthalmology residency program Wills Eye Hospital Philadelphia, Pennsylvania by Cherie Fathy, MD, Ollya Fromal, MD, Samir Patel, MD, Travis Peck, MD, Marisa Schoen, MD, Meera Sivalingam, MD Review of "Pupil expansion device use and operative outcomes with topical dilation versus intracameral epinephrine in resident-performed cataract surgery" tropicamide 1%, preservative-free lidocaine 1% mixed 9:1 with 1:1000 bisulfite-free epinephrine given at the beginning of the case without any additional epinephrine in the irrigating fluid). The two study periods were selected based on a change in perioperative pupil dilation protocol from topical dilation to intracameral dilation. Each study period included two and a half res- ident rotations over the same 6-month period a year apart. Cases were included if the resi- dent surgeon was the primary cataract surgeon without significant intervention by the attending surgeon, and the dilation protocol adhered to the mydriatic protocol. This information was derived from procedure reports. Age, gender, history of tamsulosin use, PED use during surgery, case surgical times, and the surgical costs for dilation and PED use were compared for the two study groups. Fisher's ex- act two-tailed test was used to compare the use of PED between the two groups. Paired t-tests were used to test for differences in surgical times between the two study groups. Each study group included 267 cases and were remarkably similar in the reported patient characteristics: average patient age of 72.5 years old, 97% males, and 28% use of tamsulosin in 2017 versus 29% in 2018 among the study pa- tients. For the topical mydriasis group, 31.1% of cases required PED use. Conversely, only 13.5% of intracameral mydriasis cases required PED use. For those patients on tamsulosin, PED use was 52.7% in the topical group compared to 17.9% in the intracameral group. The use of PEDs added, on average, 7.1 minutes to the surgical time compared to cases without PED use. Intracameral use did not change surgical times among PGY3 surgeons but did result in a small decrease in surgical times among PGY4 cases. In comparing surgical cost, the total cost for the use of topical mydriatics was $13,990 in A dequate pupillary dilation is essential for successful cataract extraction. Poor dilation can lead to a multitude of surgical complications includ- ing capsular rupture, iris trauma, endothelial damage, and overall poor visual outcomes. Topical pharmacologic pupillary dilation has been the traditional standard of care, however, disad- vantages include unpredictable dilation, long induction time, corneal toxicity, and systemic absorption. The advent of pupillary expansion devices (PED) has provided an additional tool to improve pupillary dilation; however, their use is associated with increased operative time, increased cost, and iris injury. Recently, intraca- meral mydriatics have gained popularity due to their rapid onset, longer maintenance of dila- tion, reduced incidence of intraoperative floppy iris syndrome, and reduced use of PED. Although intracameral mydriatics have been widely adopted, their utility in resident train- ee surgery has not been studied. This article examines the use of PED, operative times, and surgical costs with traditional topical mydriatics versus intracameral mydriatics during resident- performed cataract extraction at a Veterans Affairs hospital. Summary In this retrospective study, resident-performed cataract surgeries at the Iowa City Veterans Af- fairs Hospital performed in two different time periods (June 2017 to December 2017 and June 2018 to December 2018) were reviewed for dif- ferences in PED use, operating times, and surgi- cal costs when using traditional topical dilation (tropicamide 1%, cyclopentolate 1%, and phen- ylephrine 2.5% with 0.5 mL of preservative-free 1% lidocaine given intracamerally at the start of surgery and 1:1000 epinephrine within irriga- tion fluid) versus intracameral mydriasis (topical EYEWORLD JOURNAL CLUB

• Blank Page
• Blank Page (1)