1 0 4
1 0 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 • J A N U A R Y 2 0 1 6
A
large, stable pupil makes cataract surgery 10 times easier, so
the bigger a patient's pupil is dilated, the better. While every
patient gets pre-op drops to do the job, if you do enough
cases, you'll likely see at least one difficult pupil every day. For those
cases, you can turn to the drugs and devices that open stubborn
pupils.
• Dilating drugs. If enough time passes after the administration of pre-
op drops and a patient still isn't dilated as well as we'd like — maybe
the Flomax he's taking for his prostate is causing intraoperative flop-
py iris syndrome, maybe she's diabetic or suffers from pseudoexfolia-
tion — we have several other pharmaceutical agents we can try.
Some phenylephrine formulations can cost hundreds of dollars for a
single dose, while preservative-free ephinephrine and lidocaine can be
compounded with balanced salt solution to create "Shugarcaine" for 8
patients at a total cost of about $35. While you'll notice the pupil
shrinking during the course of a case, you'll want it to be at its largest
for the capsulorhexis. Which means it'll be more effective to start off
with a bolus of epinephrine, as Shugarcaine offers, than to dose small
amounts of it throughout, as some formulations do.
• Mechanical solutions. If the pharmaceutical options don't deliver dila-
tion, mechanical options can safely expand the iris to increase the
field of view and improve access to the lens. Fifteen to 20 years ago,
we had iris hooks, which gently stretched the pupil, but implantable
iris rings have been a game changer. No matter how small the pupil is,
they're guaranteed to hold it open to a workable size. While I've found
I rarely require expansion rings, they can get you though a worst-case
Pupil Dilation Solutions
Drugs and devices to tame even the most difficult pupils.
THINKING OF BUYING …
T. Hunter Newsom, MD
