pen-like device with a nitinol loop that's used to quarter cataracts,
making extraction easier. "We now have tools that can help us reduce
ultrasound time and energy, and the movement of instruments within
the capsular bag," says Dr. Whitman.
3. Pupil dilation
Maintaining adequate pupil size during cataract surgery is obviously
important. "You run into problems if you can't see what you're doing,"
says Dr. Whitman. He'll operate on softer cataracts with pupils at 4.5
mm to 5 mm, but prefers to begin with the pupil at 6 mm during cases
involving dense cataracts.
Intraoperative miosis naturally occurs during procedures, and even
a millimeter of constriction can significantly impact visualization of
the anterior chamber. Omidria, an FDA-approved irrigating solution
containing phenylephrine and ketorolac administered through bal-
anced saline solution, is an effective option for maintaining pupil dila-
tion, says Dr. Whitman, adding that pupillary rings and expanders "are
guaranteed to work" in patients with small pupillary openings.
Many surgeons use epinephrine-Shugarcaine solutions as an intracam-
eral anesthesia and to maintain pupil dilation, says Dr. Whitman, who
prefers to use phenylcaine, which contains the dilating agent phenyle-
phrine and the local anesthetic lidocaine. The combination keeps pupils
open wider and longer than epi-Shugarcaine and maintains dilation for
an entire case, he says, especially when using today's quicker and more
efficient phaco systems.
Calm confidence
Dr. Whitman has performed close to 60,000 cataract procedures, but
still feels a twinge of fear every time he peers into the oculars and
considers the long list of potential complications that could occur dur-
9 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • M A Y 2 0 1 9
