Eyeworld

EW CATARACT 37 September 2017 by Liz Hillman EyeWorld Staff Writer When he does decide to employ mechanical pupil expansion, Dr. Weber said he always uses a ring, unless the hooks confer a significant advantage, such as in the case of an extremely floppy iris that risks flop- ping out of the ring or a complex case with greater manipulation. "I make the decision to use a pupil expanding device after initial placement of viscoelastic, but it is never too late to use these devices and I will, if necessary, later in a case," Dr. Weber said. A ring is usually Dr. Crandall's first choice as well. Specific cases where he might prefer hooks include a very dense lens that might require conversion to extracapsular lens extraction and in cases of eccentric pupils, colobomas, and incomplete iris. "If I decide later in a case that I need pupil expansion, I am more likely to choose hooks, since it can be more difficult to place a Malyu- gin Ring [MicroSurgical Technology, Redmond, Washington] without catching it on the capsule edge," he added. floppy iris syndrome (IFIS), and will be more likely to use pupil expan- sion of some kind. If it undulates only in one area, you also have to be concerned about zonular issues in that area," Dr. Crandall said. "If there are any other ocular issues that I am worried about, it will lower my threshold to use pupil expansion. For example, if it's a dense lens or white lens, or a posterior polar lens, I'll be more likely to use pupil expansion. This eliminates one of the variables that I need to worry about, so I can concentrate on other things." Dr. Weber also said he'll start thinking about using a pupil expan- sion device if he sees evidence of floppy iris. "If a patient dilates poorly and has a history of alpha-blocker use, I'll use a pupillary expanding device," he said. "If they dilate well but demonstrate signs of IFIS, I usually will only change my phaco fluidics. If they dilate poorly due to coexisting pathology such as pseudoexfoliation, I might simply change my fluidics in anticipation that the pupil will have stable dila- tion throughout the case." The basics of small pupil management T he importance of adequate pupil dilation during cataract surgery cannot be understated. Intraoperative miosis increases the incidence of surgical compli- cations, including posterior capsular tear, vitreous loss, iris damage, corneal edema, and retained cortical material. 1 The most common risk factors for intraoperative miosis include the use of alpha blockers, pseudoexfoliation, diabetes, and femtosecond laser-assisted sur- gery. Thankfully, the number of tools available to surgeons for combating this problem is expanding, which should lead to fewer overall complications. In addition to the use of preoperative mydriatics, there are multiple medications that are commonly used to prevent intraop- erative miosis. These include preoperative topical nonsteroidal anti-inflammatory drops (NSAIDs) and intracameral epinephrine and phenylephrine. More recently, surgeons have begun using a mixture of intracameral phen- ylephrine 1.0% and ketorolac 0.3%, known as Omidria (Omeros, Seattle), that is placed as an additive into the irrigation solution during cataract surgery. Donnenfeld et al. 2 published a prospective randomized control trial of 223 patients demonstrating that patients receiving Omidria had significantly better maintenance of mydriasis during cataract surgery. I have found Omidria to be a useful addition to my pupil management armamentarium, partic- ularly for patients I have identified as poor dilators at the slit lamp. In this month's "YES connect" column, Charles Weber, MD, and David Crandall, MD, share their approaches to managing a small pupil. They focus on the value of pupil expanding devices in cases where intraopera- tive floppy iris syndrome (IFIS) is expected and in cases of marginal dilation that may prove to be complex or lengthy due to lens/zonular pathology. The discussion highlights pearls for safely and effectively using these devices— techniques every surgeon should master. Zachary Zavodni, MD YES connect co-editor References 1. Silverstein SM, et al. Rates of complications associated with intraoperative miosis during cataract surgery in the U.S. Presented at the 2016 ASCRS•ASOA Symposium & Congress. 2. Donnenfeld ED, et al. Intracameral ketorolac and phenylephrine effect on intraoperative pupil diameter and postoperative pain in cataract surgery. J Cataract Refract Surg. 2017;43:597–605. YES connect continued on page 39 In the case of a floppy iris or a complex case with greater manipulation, Dr. Weber prefers using iris hooks over a ring. Source: Charles Weber, MD From mydriatics to pupil expanders, how and when to use them S mall pupils can pose a challenge to even experi- enced cataract surgeons, limiting visualization of various lens and cataract structures. They are often associated with other conditions, such as syn- echiae, pseudoexfoliation, diabetes, or narrow-angle glaucoma. Without adequate dilation, iris trauma or capsule tearing could oc- cur. 1 Fortunately, there are a variety of pharmacological and mechanical techniques to safely and adequately dilate or expand the pupil. Mydriatics are often a first-line choice to dilate the pupil. Charles Weber, MD, The Eye Institute of Utah, Salt Lake City, said he uses an intracameral mydriatic—lidocaine with epinephrine—at the start of every case. David Crandall, MD, Henry Ford Health System, Detroit, on the other hand, said he'll use 1.5% phenylephrine only in cases where he thinks he'll need extra dilation. Dr. Weber and Dr. Crandall said they don't use a mydriatic agent with ketorolac, an anti-inflammato- ry agent. Omidria (Omeros, Seattle, Washington), a combination of ketorolac and phenylephrine, is designed to provide both pupil dila- tion and pain management. Phase 3 clinical studies published in 2015 (approval from the U.S. Food and Drug Administration was granted in 2014) reported that the combination was safe and effective at maintaining mydriasis and reducing postopera- tive pain. 2 If dilation is not enough with a mydriatic agent or if there are other conditions that might merit the need for further iris expansion and support, a pupil expansion device could be used. Dr. Crandall said he tries to identify any possible issues with pupil size that might merit a pupil expansion device preoperative- ly in the clinic to be as prepared for surgery as possible. "If I have a pupil that is mar- ginal in diameter, when I infuse lidocaine into the anterior chamber, I'll aim the cannula at the iris. If it undulates significantly, then I am concerned about intraoperative

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