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Consultation section
Q:
For extracapsular cataract extraction (ECCE) , what
is your routine for dilating the pupil preoperatively and
maintaining dilation intraoperatively? Dennis D. Shephard, M.D.
Santa Maria, California
A:
My routine for dilating the pupil preoperatively is cyclopentolate hydrochloride, phenylephrine hydrochloride (Cyclomydril®) alternating with phenylephrine hydrochloride (Neo-Synephrine®) 2.5% in two sets with five minutes between the two drops. This is started 60 minutes prior to surgery. A third set is given to the patient on his or her way to the operating room. For maintaining dilation during the procedure, 0.5 ml of epinephrine 1:1,000 intracardiac solution is added to the 500 ml bottle of balanced salt solution (BSS®) used for irrigation. The pupil is not dilated for 48 hours prior to surgery. Aziz Anis, M.D. Lincoln, Nebraska
consultation section Edited by Dennis D. Shepard, M.D.
A:
On the day before surgery, before YAG laser anterior capsulotomy, I use homatropine 5.0% and NeoSynephrine 2.5%. After the patient is admitted to the hospital, I use homatropine 5.0% every three hours while the patient is awake and in the AM. Before cataract surgery, I use Cyclomydril and Neo-Synephrine 10.0%. These drops are usually used just once, but may be repeated if the pupil does not dilate well. During surgery, I use epinephrine (Adrenalin ®) 1:10,000 behind the iris (much more effective in this position). Robert C. Drews, M.D.
Clayton, Missouri
A:
I routinely dilate my patients with one drop ·of cyclopentolate hydrochloride (Cyclogyl®) 1.0% and one drop of Neo-Synephrine 2.5% two hours before surgery. Intraoperatively, I use 0.5 cc of intracardiac Adrenalin 1:1,000 in the 500 cc bottle of BSS Plus. Robert M. Sinskey, M.D.
Santa Monica, California
78
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, JANUARY 1985
A:
Preoperatively, I dilate the pupil with Cyclomydril, two drops every ten minutes x three beginning one hour before surgery. Intraoperatively, if there are no medical contraindications, I use 0.25 cc of intracardiac Adrenalin mixed with 500 cc ofBSS. In addition, maintaining a closed-eye surgical environment with normotensive intraocular pressure greatly facilitates continued pupillary mydriasis. K. Buol Heslin, M.D.
"push-pull" hook (manufactured by many instrument companies) to manipulate a pupil for removal of cortex. In patients who have been on miotics for several years and whose pupils will not dilate adequately, we do a sector iridectomy by completing a peripheral iridectomy to the sphincter, thus creating a "keyhole pupil." We do not feel it is necessary to suture these pupils together postoperatively since they are unnoticeable in most dark irides. The repair of this pupil defect may be performed in a patient with a blue iris. C. Fredrick Milkie, M.D. H. John Shammas, M.D.
New York, New York
Lynwood, California
A:
For preoperative mydriasis, I use Cyclogyl 1% and Neo-Synephrine 10%. These drops are begun one half to one hour before surgery and are alternated every five minutes for one dose of each if the patient is less than 50 years old, or two doses of each if the patient is older. If this does not dilate the pupil adequately, it is unlikely that any other pharmacologic regimen will. No dilating agent is added to the irrigating solution. If the pupil is of adequate size at the beginning of surgery, it usually remains this way for cortical aspiration and IOL insertion. Pupils that cause problems by constricting during the surgical procedure are those that were only marginally dilated at the start. Maintaining intraoperative pupillary dilation is more critical (and more difficult) for phacoemulsification than for nuclear extraction. I like to have a miotic pupil at the conclusion of surgery. To achieve this goal, I instill acetylcholine chloride (Miochol®), preferably, or carbachol (Miostat®) posterior to the sodium hyaluronate (Healon ®) - that is, between the Healon ® and the iris. This technique concentrates the miotic agent where it belongs, against the iris, and is much more effective than irrigating the entire anterior chamber with the miotic. Ronald W. Barnet, M.D. Phoenix, Arizona
A:
A:
I routinely use Cyclogyll.O% and Neo-Synephrine eye drops 2.5% , each given three times over a tenminute period, approximately 40 minutes preoperatively. Occasionally, I will add Neo-Synephrine 10.0% to patients who are not hypertensive. Intraoperatively, after the stab incisions and just prior to anterior capsulotomy, I inject approximately 0.25 cc of Adrenalin 1:10,000 mixed with BSS solution. Then, during the procedure (phacoemulsification or planned ECCE) I use BSS or BSS Plus irrigating solution with Adrenalin 1:300,000. David B. Davis II, M.D. Hayward, California
A:
I dilate the pupil with a combination of tropicamide (Mydriacyl®) 0.5% and Neo-Synephrine 2.5%. The drops are used one hour, one half hour, and on call in the operating room. For planned ECCE, I use the Simcoe technique, which does not require any irrigating solution. Probably 95% of my cases are done with phacoemulsification; for that I use three drops of epinephrine 1:1,000 in 500 cc of BSS. Donald L. Praeger, M.D.
New York, New York
Preoperatively, on admission we instill N eoSynephrine 10.0% and Cyclogyll.O% three times at 30 minute intervals. We perform our surgery in a surgery center, which allows adequate time for the patient to enter the surgical schedule. In the operating room we use warm BSS Plus with 0.3 mlofepinephrine 1:1,000. On occasion, Healon ® may be used to dilate a pupil mechanically for insertion of an intraocular implant or to aid removal of cortical material. We also use the
A:
My routine procedure for dilating the pupil preoperatively is to use phenylephrine hydrochloride 10% and scopolamine hydrobromide 0.3% (Murocoll-2®) drops, one every five minutes x 12. I usually order x 12 because that insures the patient's getting at least six drops. During surgery, I have 0.5 cc of Adrenalin in a 500 cc
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, JANUARY 1985
79
bottle of balanced salt solution for maintaining pupillary dilation. Manus C. Kraff, M.D.
A:
One hour before the operation, I use Cyclogyl and Mydriacyl; five minutes later the same again. Twenty minutes before starting surgery, I use 10% NeoSynephrine aqueous solution. If necessary, this is repeated five minutes later. Intraoperatively, I occasionally use epinephrine 1:1,000 ml in 500 ml BSS for the irrigation/aspiration solution during planned ECCE.
For planned extracapsular cataract extraction, I most often use Cyclogyll.O% and Mydfrin 2.5% preoperatively, one drop of each x 3 about one hour prior to retrobulbar injection. I rarely find it necessary to give more than six drops preoperatively. On the operating room flow sheet, the exact time and number of drops given are recorded, initialed by a staff member. I have never used any medication for maintaining pupil dilation intraoperatively. It is my personal conviction that the less you assault the eye with a variety of medications, preoperatively, intraoperatively, and postoperatively, the better the result.
Karl Jacobi, M. D.
John H. Park, M.D.
Chicago, Illinois
A:
Giessen, West Germany
80
Buffalo, New York
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, JANUARY 1985
For extracapsular cataract extraction (ECCE) , what
is your routine for dilating the pupil preoperatively and
maintaining dilation intraoperatively? Dennis D. Shephard, M.D.
Santa Maria, California
A:
My routine for dilating the pupil preoperatively is cyclopentolate hydrochloride, phenylephrine hydrochloride (Cyclomydril®) alternating with phenylephrine hydrochloride (Neo-Synephrine®) 2.5% in two sets with five minutes between the two drops. This is started 60 minutes prior to surgery. A third set is given to the patient on his or her way to the operating room. For maintaining dilation during the procedure, 0.5 ml of epinephrine 1:1,000 intracardiac solution is added to the 500 ml bottle of balanced salt solution (BSS®) used for irrigation. The pupil is not dilated for 48 hours prior to surgery. Aziz Anis, M.D. Lincoln, Nebraska
consultation section Edited by Dennis D. Shepard, M.D.
A:
On the day before surgery, before YAG laser anterior capsulotomy, I use homatropine 5.0% and NeoSynephrine 2.5%. After the patient is admitted to the hospital, I use homatropine 5.0% every three hours while the patient is awake and in the AM. Before cataract surgery, I use Cyclomydril and Neo-Synephrine 10.0%. These drops are usually used just once, but may be repeated if the pupil does not dilate well. During surgery, I use epinephrine (Adrenalin ®) 1:10,000 behind the iris (much more effective in this position). Robert C. Drews, M.D.
Clayton, Missouri
A:
I routinely dilate my patients with one drop ·of cyclopentolate hydrochloride (Cyclogyl®) 1.0% and one drop of Neo-Synephrine 2.5% two hours before surgery. Intraoperatively, I use 0.5 cc of intracardiac Adrenalin 1:1,000 in the 500 cc bottle of BSS Plus. Robert M. Sinskey, M.D.
Santa Monica, California
78
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, JANUARY 1985
A:
Preoperatively, I dilate the pupil with Cyclomydril, two drops every ten minutes x three beginning one hour before surgery. Intraoperatively, if there are no medical contraindications, I use 0.25 cc of intracardiac Adrenalin mixed with 500 cc ofBSS. In addition, maintaining a closed-eye surgical environment with normotensive intraocular pressure greatly facilitates continued pupillary mydriasis. K. Buol Heslin, M.D.
"push-pull" hook (manufactured by many instrument companies) to manipulate a pupil for removal of cortex. In patients who have been on miotics for several years and whose pupils will not dilate adequately, we do a sector iridectomy by completing a peripheral iridectomy to the sphincter, thus creating a "keyhole pupil." We do not feel it is necessary to suture these pupils together postoperatively since they are unnoticeable in most dark irides. The repair of this pupil defect may be performed in a patient with a blue iris. C. Fredrick Milkie, M.D. H. John Shammas, M.D.
New York, New York
Lynwood, California
A:
For preoperative mydriasis, I use Cyclogyl 1% and Neo-Synephrine 10%. These drops are begun one half to one hour before surgery and are alternated every five minutes for one dose of each if the patient is less than 50 years old, or two doses of each if the patient is older. If this does not dilate the pupil adequately, it is unlikely that any other pharmacologic regimen will. No dilating agent is added to the irrigating solution. If the pupil is of adequate size at the beginning of surgery, it usually remains this way for cortical aspiration and IOL insertion. Pupils that cause problems by constricting during the surgical procedure are those that were only marginally dilated at the start. Maintaining intraoperative pupillary dilation is more critical (and more difficult) for phacoemulsification than for nuclear extraction. I like to have a miotic pupil at the conclusion of surgery. To achieve this goal, I instill acetylcholine chloride (Miochol®), preferably, or carbachol (Miostat®) posterior to the sodium hyaluronate (Healon ®) - that is, between the Healon ® and the iris. This technique concentrates the miotic agent where it belongs, against the iris, and is much more effective than irrigating the entire anterior chamber with the miotic. Ronald W. Barnet, M.D. Phoenix, Arizona
A:
A:
I routinely use Cyclogyll.O% and Neo-Synephrine eye drops 2.5% , each given three times over a tenminute period, approximately 40 minutes preoperatively. Occasionally, I will add Neo-Synephrine 10.0% to patients who are not hypertensive. Intraoperatively, after the stab incisions and just prior to anterior capsulotomy, I inject approximately 0.25 cc of Adrenalin 1:10,000 mixed with BSS solution. Then, during the procedure (phacoemulsification or planned ECCE) I use BSS or BSS Plus irrigating solution with Adrenalin 1:300,000. David B. Davis II, M.D. Hayward, California
A:
I dilate the pupil with a combination of tropicamide (Mydriacyl®) 0.5% and Neo-Synephrine 2.5%. The drops are used one hour, one half hour, and on call in the operating room. For planned ECCE, I use the Simcoe technique, which does not require any irrigating solution. Probably 95% of my cases are done with phacoemulsification; for that I use three drops of epinephrine 1:1,000 in 500 cc of BSS. Donald L. Praeger, M.D.
New York, New York
Preoperatively, on admission we instill N eoSynephrine 10.0% and Cyclogyll.O% three times at 30 minute intervals. We perform our surgery in a surgery center, which allows adequate time for the patient to enter the surgical schedule. In the operating room we use warm BSS Plus with 0.3 mlofepinephrine 1:1,000. On occasion, Healon ® may be used to dilate a pupil mechanically for insertion of an intraocular implant or to aid removal of cortical material. We also use the
A:
My routine procedure for dilating the pupil preoperatively is to use phenylephrine hydrochloride 10% and scopolamine hydrobromide 0.3% (Murocoll-2®) drops, one every five minutes x 12. I usually order x 12 because that insures the patient's getting at least six drops. During surgery, I have 0.5 cc of Adrenalin in a 500 cc
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, JANUARY 1985
79
bottle of balanced salt solution for maintaining pupillary dilation. Manus C. Kraff, M.D.
A:
One hour before the operation, I use Cyclogyl and Mydriacyl; five minutes later the same again. Twenty minutes before starting surgery, I use 10% NeoSynephrine aqueous solution. If necessary, this is repeated five minutes later. Intraoperatively, I occasionally use epinephrine 1:1,000 ml in 500 ml BSS for the irrigation/aspiration solution during planned ECCE.
For planned extracapsular cataract extraction, I most often use Cyclogyll.O% and Mydfrin 2.5% preoperatively, one drop of each x 3 about one hour prior to retrobulbar injection. I rarely find it necessary to give more than six drops preoperatively. On the operating room flow sheet, the exact time and number of drops given are recorded, initialed by a staff member. I have never used any medication for maintaining pupil dilation intraoperatively. It is my personal conviction that the less you assault the eye with a variety of medications, preoperatively, intraoperatively, and postoperatively, the better the result.
Karl Jacobi, M. D.
John H. Park, M.D.
Chicago, Illinois
A:
Giessen, West Germany
80
Buffalo, New York
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, JANUARY 1985