and effective surgery. Here's a rundown.
Mydriatic agents
Pharmaceutical options for maintaining pupil dilation do not involve
the mechanical manipulation of the iris, so there's less risk of cystoid
macular edema developing after surgery, says Rex Hamilton, MD, MS,
FACS, a cataract and refractive surgeon at Santa Monica (Calif.) Eye
Medical Group.
Dr. Hamilton says most surgeons routinely use topical or intracameral
agents to create intraoperative mydriasis, but differ in their drugs of
choice. He typically injects Shugarcaine (a lidocaine-epinephrine com-
pound) to keep pupils dilated.
Lidocaine provides anesthetic comfort and also paralyzes the pupil's
sphincter muscle, causing the pupil to open wide, says Kevin Miller,
MD, chief of the cataract and refractive surgery division at the David
Geffen School of Medicine at UCLA. Shugarcaine stimulates the pupil's
dilator muscle, which also helps to maintain pupil dilation, he adds.
Surgeons also commonly opt for tropicamide and phenylephrine or
a longer-lasting agent such as cyclopentolate, says Dr. Miller, adding
that NSAIDs are an underappreciated option for helping to maintain
pupil dilation.
"That's where Omidria comes into play," he says.
Omidria, the intraocular irrigating solution that's administered
through balanced saline solution during surgery, contains the NSAID
ketorolac and the dilating agent phenylephrine. It's indicated and
FDA-approved to maintain pupil dilation and improve post-op healing,
but it's also an expensive drug (about $465 per 4-ml vial) in a specialty
with razor-thin margins. However, the cost concern was mitigated
when CMS decided last October to reinstate Omidria's pass-through
status until Oct. 1, 2020. That means you can bill CMS separately for
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