Eyeworld

APRIL 2020 | EYEWORLD | 17 continued on page 18 References 1. Cionni RJ, et al. Cataract surgery without preoperative eyedrops. J Cataract Refract Surg. 2003;29:2281–2283. 2. Myers WG, Shugar JK. Opti- mizing the intracameral dilation regimen for cataract surgery: pro- spective randomized comparison of 2 solutions. J Cataract Refract Surg. 2009;35:273–276. 3. Lundberg B, Behndig A. Intra- cameral mydriatics in phacoemul- sification cataract surgery – a 6-year follow-up. Acta Ophthal- mol. 2013;91:243–246. 4. Visco D. Effect of phenyleph- rine/ketorolac on iris fixation ring use and surgical times in patients at risk of intraoperative miosis. Clin Ophthalmol. 2018;12:301– 305. 5. Winter TW, et al. Resident and fellow participation in strabismus surgery: effect of level of training and number of assistants on operative time and cost. Ophthal- mology. 2014;121:797–801. 6. Neff KD, et al. Factors associ- ated with intraoperative floppy iris syndrome. Ophthalmology. 2009;116:658–663. efficiency between the two study time periods? How much training and prior cataract surgery experience did each resident have prior to the cases included in this study? In addition, it is unclear whether cases included in the study are evenly distributed among the residents in each level and across time periods. As noted by Winter et al. in their analysis of resident and fellow participation in strabismus surgery, operative times can vary significantly based on level of experience and interest. 5 Future studies performed in a prospective and randomized manner could help eliminate some of these potential confounders. It would also be useful to have addition- al information on factors that could impact intraoperative miosis. The authors include data on tamsulosin use, which is associated with intraoperative floppy iris syndrome 6 ; however, additional factors such as prior history of uve- itis, history of pseudoexfoliation, and the type of viscoelastic used could impact the primary outcomes. The decision of whether to use PED may be influenced by these patient factors, as well as by staff ophthalmologist preference. There may be variability in preference and/or threshold to using PED in resident cases be- tween staff ophthalmologists that could affect outcomes of this study. Furthermore, retrobul- bar anesthesia may affect pupillary dilation, and selective cases were included in this study that had undergone a block prior to cataract surgery. Finally, as cases where the staff ophthalmologist performed a significant amount of the surgery were excluded from analysis, it would be inter- esting to know how many of these cases were excluded in each time period. Table 2 in the study details the cost com- parison between the two groups, showing cost per case for each of the mydriatics and surgical devices. Analysis reveals almost $20,000 in cost study group 1 ($52.40 for tropicamide, phenyl- ephrine, cyclopentolate) compared to $523 in study group 2 (solely topical tropicamide). The total cost for intraoperative epinephrine was $502 for study group 1 (irrigating bottle, $1.26 per case) versus $633 in study group 2 (intra- cameral, $1.75 per case). In 2017, 74 Malyugin rings ($130/each) and nine iris hooks ($100/set) cost $10,520. In 2018, 33 Malyugin rings and three iris hooks cost $4,590. Discussion While prior studies have shown safety and efficacy of intracameral mydriatics for pupil di- lation in cataract surgery, 1–4 this is the first study to evaluate the impact of intracameral epineph- rine on efficiency and cost of resident-per- formed cataract surgery. This was a retrospec- tive study that compared the use of topical dilation drops versus intracameral epinephrine on PED use, surgical costs, and surgical times in resident-performed cataract surgery. The authors found a reduction in the use of PED, intraoperative costs, and operative times with the use of intracameral epinephrine compared to topical dilation alone. As the authors noted, a limitation is the retrospective nature of this study. Cases were included from two time periods: June 2017 to December 2017 and June 2018 to December 2018. This time period was selected based on a change in the pupil dilation protocol at their institution that resulted in a transition to intracameral epinephrine use with topical tropicamide from traditional topical dilation with three agents (tropicamide, cyclopentolate, and phenylephrine). Additional information on possible confounders that could impact the primary outcomes would be valuable in inter- preting the findings. Could there have been a change to the surgical curriculum or the surgical instructors that could have improved surgical Wills Eye Hospital residents

• Blank Page
• Blank Page (1)