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Importance of pupil dilation for cataract surgery
583
EDITORIAL
Importance of pupil dilation for cataract surgery “The pupil dilates in darkness and in the end finds light.” dVictor Hugo, Les Miserables
has been called OMS302, or Omidria, and it is now available for use in the U.S. as an additive to the balanced salt solution used for irrigation during cataract surgery. This formulation Multiple studies over the past 25 years is not only preservative-free, but also bisulfitehave found that adequate initial pupil dilafree. An additional advantage to the use of this tion as well as maintenance of dilation durmedication is that not only does it maintain ing surgery are necessary for safe and pupil mydriasis, it also has the ability to efficient cataract surgery. A metaanalysis decrease postoperative pain in cataract evaluated 40 studies of intraoperative miosis patients. from 1982 to 2014.A It found numerous In this issue of the journal, Donnenfeld complications associated with inadequate and coauthors (pages 597–605) present Nick Mamalis, MD initial mydriasis or intraoperative miosis the results of a randomized doubleduring cataract surgeries, such as an masked control study evaluating the increased incidence of posterior capsule tear, vitreous loss, components in the OMS302 compound, both individuand zonular fiber breaks. In addition, there is also an ally and together, as well as comparisons to a balanced increased risk for possible iris damage and iris chafing if the salt solution vehicle as a control. Videos were taken durpupil is not adequately dilated during cataract surgery. There ing cataract surgery, and the pupil diameter was is also an increased risk for retained lens cortical material if measured at 1-minute intervals by video capture. In addithe pupil is inadequately dilated during surgery. Finally, comtion, the study evaluated postoperative ocular pain for up plications such as corneal edema and cystoid macular edema to 12 hours after cataract surgery. The results showed that can occur secondary to intraoperative miosis. the OMS302 compound was significantly better than the There are multiple different ways of obtaining adequate vehicle and the individual ketorolac in maintaining pupil dilation before cataract surgery, including the use of mydriasis during cataract surgery. Significantly fewer topical mydriatic drops such as tropicamide, cyclopentopatients treated with the combination medication had late, and phenylephrine hydrochloride. In addition, topical intraoperative pupil diameters smaller than 6.0 mm nonsteroidal antiinflammatory drops (NSAIDs) have also compared with those treated with the vehicle as well as been shown to prevent intraoperative miosis or constriction the individual components of ketorolac and phenylephof the pupil during cataract surgery. An ASCRS Cataract rine. In addition, fewer patients who were administered Clinical Committee white paper reviewed multiple different phenylephrine alone or ketorolac alone had constricted strategies in the management of the pupil in intraoperative pupils during surgery than patients given the vehicle. floppy-iris syndrome (IFIS).1 Medications, including The combination of these 2 medications had a greater or more than additive effect relative to each in preventing epinephrine compounds, can also be used during cataract intraoperative miosis. surgery itself to help prevent intraoperative miosis. More This study also evaluated postoperative pain and recently, phenylephrine was found to help maintain mydrifound that the combination of the 2 medications signifiasis during cataract surgery when used intracamerally or in cantly reduced postoperative pain compared with the the irrigating solution during cataract surgery. Phenylephphenylephrine-treated patients and vehicle-treated patients. rine preferentially stimulates a-adrenergic receptors to One of the exclusion criteria in this study was a history of decrease the propensity for intraocular miosis. Studies perthe use of an a1-adrenergic antagonist preoperatively. formed outside the United States found intracameral phenylephrine 1.5% mixture to be highly effective in Although the OMS302 compound was found to provide maintaining pupil dilation during cataract surgery, espeexcellent mydriasis during cataract surgery and to help precially in patients with IFIS.2 vent intraoperative miosis, the potential area of further research is to see whether this compound is helpful in the A new medication has been developed that contains a prophylaxis of IFIS patients who have been on a1-adrenmixture of the a1-adrenergic receptor agonist phenylephrine as well as the NSAID ketorolac, which is a relatively nonselective ergic medications for prostate disease. In Europe, incyclooxygenase-1/cyclooxygenase-2 inhibitor. This medication tracameral phenylephrine 1.5% has been found to be Q 2017 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.05.018
584
EDITORIAL
highly effective for prophylaxis in these IFIS patients. It will be important to see whether the combination of phenylephrine and ketorolac compound added to the balanced salt solution during cataract surgery is also able to maintain miosis in these difficult surgical patients. This could help decrease the need for intraoperative devices to maintain pupil dilation during cataract surgery, such as iris hooks or various ring-shaped devices, in this group of patients. Medications that can safely maintain mydriasis during cataract surgery have the potential to reduce intraoperative complications by better maintaining an adequate pupil diameter during cataract surgery. A well-dilated pupil during cataract surgery can decrease the incidence of posterior capsule tears as well as vitreous loss, zonular fiber disruption, and remnant lens material. This can help provide better outcomes after cataract surgery and could be especially
Volume 43 Issue 5 May 2017
important in the era of premium intraocular lenses and more demanding patients and cataract surgeons. Nick Mamalis, MD REFERENCES
1. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M, for the ASCRS Cataract Clinical Committee. ASCRS white paper: Clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2008; 34:2153–2162. Available at: http://www.ascrs.org/sites/ default/files/resources/JCRS%20IFIS%20White%20Paper%2012-08.pdf. Accessed May 17, 2017 2. Manvikar S, Allen D. Cataract surgery management in patients taking tamsulosin; staged approach. J Cataract Refract Surg 2006; 32:1611–1614
OTHER CITED MATERIAL A. Silverstein SM, Katsev DA, Connolly M, Sierra MI, Schaaf DT, Melfi CA, “Rates of Complications Associated with Intraoperative Miosis During Cataract Surgery in the U.S.,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016
EDITORIAL
Importance of pupil dilation for cataract surgery “The pupil dilates in darkness and in the end finds light.” dVictor Hugo, Les Miserables
has been called OMS302, or Omidria, and it is now available for use in the U.S. as an additive to the balanced salt solution used for irrigation during cataract surgery. This formulation Multiple studies over the past 25 years is not only preservative-free, but also bisulfitehave found that adequate initial pupil dilafree. An additional advantage to the use of this tion as well as maintenance of dilation durmedication is that not only does it maintain ing surgery are necessary for safe and pupil mydriasis, it also has the ability to efficient cataract surgery. A metaanalysis decrease postoperative pain in cataract evaluated 40 studies of intraoperative miosis patients. from 1982 to 2014.A It found numerous In this issue of the journal, Donnenfeld complications associated with inadequate and coauthors (pages 597–605) present Nick Mamalis, MD initial mydriasis or intraoperative miosis the results of a randomized doubleduring cataract surgeries, such as an masked control study evaluating the increased incidence of posterior capsule tear, vitreous loss, components in the OMS302 compound, both individuand zonular fiber breaks. In addition, there is also an ally and together, as well as comparisons to a balanced increased risk for possible iris damage and iris chafing if the salt solution vehicle as a control. Videos were taken durpupil is not adequately dilated during cataract surgery. There ing cataract surgery, and the pupil diameter was is also an increased risk for retained lens cortical material if measured at 1-minute intervals by video capture. In addithe pupil is inadequately dilated during surgery. Finally, comtion, the study evaluated postoperative ocular pain for up plications such as corneal edema and cystoid macular edema to 12 hours after cataract surgery. The results showed that can occur secondary to intraoperative miosis. the OMS302 compound was significantly better than the There are multiple different ways of obtaining adequate vehicle and the individual ketorolac in maintaining pupil dilation before cataract surgery, including the use of mydriasis during cataract surgery. Significantly fewer topical mydriatic drops such as tropicamide, cyclopentopatients treated with the combination medication had late, and phenylephrine hydrochloride. In addition, topical intraoperative pupil diameters smaller than 6.0 mm nonsteroidal antiinflammatory drops (NSAIDs) have also compared with those treated with the vehicle as well as been shown to prevent intraoperative miosis or constriction the individual components of ketorolac and phenylephof the pupil during cataract surgery. An ASCRS Cataract rine. In addition, fewer patients who were administered Clinical Committee white paper reviewed multiple different phenylephrine alone or ketorolac alone had constricted strategies in the management of the pupil in intraoperative pupils during surgery than patients given the vehicle. floppy-iris syndrome (IFIS).1 Medications, including The combination of these 2 medications had a greater or more than additive effect relative to each in preventing epinephrine compounds, can also be used during cataract intraoperative miosis. surgery itself to help prevent intraoperative miosis. More This study also evaluated postoperative pain and recently, phenylephrine was found to help maintain mydrifound that the combination of the 2 medications signifiasis during cataract surgery when used intracamerally or in cantly reduced postoperative pain compared with the the irrigating solution during cataract surgery. Phenylephphenylephrine-treated patients and vehicle-treated patients. rine preferentially stimulates a-adrenergic receptors to One of the exclusion criteria in this study was a history of decrease the propensity for intraocular miosis. Studies perthe use of an a1-adrenergic antagonist preoperatively. formed outside the United States found intracameral phenylephrine 1.5% mixture to be highly effective in Although the OMS302 compound was found to provide maintaining pupil dilation during cataract surgery, espeexcellent mydriasis during cataract surgery and to help precially in patients with IFIS.2 vent intraoperative miosis, the potential area of further research is to see whether this compound is helpful in the A new medication has been developed that contains a prophylaxis of IFIS patients who have been on a1-adrenmixture of the a1-adrenergic receptor agonist phenylephrine as well as the NSAID ketorolac, which is a relatively nonselective ergic medications for prostate disease. In Europe, incyclooxygenase-1/cyclooxygenase-2 inhibitor. This medication tracameral phenylephrine 1.5% has been found to be Q 2017 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.05.018
584
EDITORIAL
highly effective for prophylaxis in these IFIS patients. It will be important to see whether the combination of phenylephrine and ketorolac compound added to the balanced salt solution during cataract surgery is also able to maintain miosis in these difficult surgical patients. This could help decrease the need for intraoperative devices to maintain pupil dilation during cataract surgery, such as iris hooks or various ring-shaped devices, in this group of patients. Medications that can safely maintain mydriasis during cataract surgery have the potential to reduce intraoperative complications by better maintaining an adequate pupil diameter during cataract surgery. A well-dilated pupil during cataract surgery can decrease the incidence of posterior capsule tears as well as vitreous loss, zonular fiber disruption, and remnant lens material. This can help provide better outcomes after cataract surgery and could be especially
Volume 43 Issue 5 May 2017
important in the era of premium intraocular lenses and more demanding patients and cataract surgeons. Nick Mamalis, MD REFERENCES
1. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M, for the ASCRS Cataract Clinical Committee. ASCRS white paper: Clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2008; 34:2153–2162. Available at: http://www.ascrs.org/sites/ default/files/resources/JCRS%20IFIS%20White%20Paper%2012-08.pdf. Accessed May 17, 2017 2. Manvikar S, Allen D. Cataract surgery management in patients taking tamsulosin; staged approach. J Cataract Refract Surg 2006; 32:1611–1614
OTHER CITED MATERIAL A. Silverstein SM, Katsev DA, Connolly M, Sierra MI, Schaaf DT, Melfi CA, “Rates of Complications Associated with Intraoperative Miosis During Cataract Surgery in the U.S.,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016