in Cataract Surgery William W. Culbertson, MD

Pupil

Managing the Misbehaving

• Consultant: OptiMedica • Fees for Non-CME Services: Alcon

Laboratories, Inc. • Contracted Research: Carl Zeiss Meditec • Ownership Interest: OptiMedica

Financial Disclosure

The Problem With Cataract Surgery in Small Pupils:

Higher incidence of complications • iris / pupil / corneal damage • retained lens material • small capsulorhexis • torn / broken anterior or posterior capsule • retained viscoelastic • malpositioning of IOL • prolonged/painful surgery

Causes of Small Pupils in Cataract Surgery:

Anatomically small pupil: advanced age congenital pupil abnormalities Pathologic conditions: dystrophic essential iris atrophy pseudoexfoliation restrictive posterior synechia pupil membranes (uveitis, trauma) pupil fibrosis (previous trauma, surgery,

miotics) Physiologic conditions: Tamsulosin Miotics Inflammation

Pre operative assessment: History: Ocular history of glaucoma Rx., uveitis, trauma, surgery Medications: tamsulosin, terazosin, doxazosin,

dutasteride/tamsulosin Examination: Pupil size in dim and bright light

(for multifocal IOL) Pupil position Pupil reactions to light Pupil dilation after mydriatic agents

Strategies to Deal With Small Pupils:

Prevention: Eliminate miotic Pre-op NSAID - Confirm mydriatic drops pre-op Epinephrine in infusion (0.1ml of 1:1000) Avoid iris manipulation Retrobulbar anesthesia Intraocular

Anticholinergic

cyclopentolate 1.0%

atropine 1% / hyoscine 0.25%

Sympathomimetic

phenylephrine 2.5%

Strategies to Deal With Small Pupils:

Prevention: Eliminate miotic Pre-op NSAID Confirm mydriatic drops pre-op Epinephrine in infusion (0.1ml of 1:1000) Avoid iris manipulation Retrobulbar anesthesia Intraocular:

preservative free 1% lidocaine bisulfite free epineprine/phenylephrine

Strategies to Deal With Small Pupils:

Prevention: Eliminate miotic Pre-op NSAID Confirm mydriatic drops pre-op Epinephrine in infusion (0.1ml of 1:1000) Avoid iris manipulation Retrobulbar anesthesia Intraocular Epi-Shugarcaine (for IFIS) Shugarcaine

Strategies to Deal With Small Pupils:

Preparation: 1. Known to have small pupil pre-op &/or likely to have small

pupil intraop – have a plan ready: Pupil stretchers: 2 Kuglen hooks; Beehler etc. Pupil expansion devices: hooks, rings 2. Develops pupil constriction during surgery: Have emergency kit with all pupil devices and meds ready.

Enlarging the Restricted Pupil

• Break posterior synechiae

• Remove restrictive pupil membrane

• Add dispersive viscoelastic

• Use pupil stretching device(s) if necessary Kuglen hooks Beehler pupil expander

• Pupil expanding devices usually not necessary for

restricted pupil

Intraoperative Enlargment of the Physiologically Small

(but not restricted) Pupil Pharmacologic stimulation Dispersive viscoelastic (Healon V) Pupil stretching devices Pupil expanding devices Iris hooks Graether ring Morcher ring Malyugen ring

Synechiolysis and Expansion with Healon V

Shugarcaine and epi-Shugarcaine

• Shugarcaine (intracameral dilation) Use 1.0ml – 1.0ml 4% preservative free lidocaine – 3.0ml BSS Plus

• Epi-Shugarcaine (floppy iris) Use 1.0ml intracameral – 0.25ml 1:1000 bisulphate free epinephrine – 0.75ml Shugarcaine

Pupil Stretching with Two Parallel Kuglen Hooks

Beehler Pupil Stretcher

Two Prong Three Prong

Iris Hooks for Pupil

Malyugin Ring Advantages:

• Easy to insert and remove from the anterior chamber • Maintains a 6.0-7.0 mm pupil throughout the procedure • Optimal work area turns potentially difficult case into a routine

procedure • Stabilizes the iris • Easily removable • Pupil size, shape and function retained

post-operatively

Malyugin Ring in Small Pupil

Intraoperative Floppy Iris Syndrome

Triad: - Floppy, billowing iris - Iris prolapse - Progressive miosis

Managing the Tamsulosin Pupil Intraoperative Floppy Iris Syndrome

• Be aware and be prepared • Stopping drug is of questionable value • Pre-op topical meds: topical NSAIDs and 1% atropine • Intraoperative meds:

(0.5ml of 1.0% lidocaine) (0.1ml of 1:1,000 epinephrine) (1.0ml of Shugarcaine) (1.0ml of epi-Shugarcaine)

(1.0ml of 1.5% phenylephrine)

Intracameral phenylephrine “BPEIcaine”

• 1.0% lidocaine

+ • Add powdered phenylephrine to bring

concentration to 1.5% • Filter through millipore filter X2 and culture

twice for two weeks • Inject 1.0ml in AC

epi-Shugarcaine in Tamsulosin Case

Managing the Tamsulosin Pupil

• If starting pupil is large try to keep it large • 1.0ml epi-Shugarcaine • More central corneal entry for incisions • Small paracentesis tract • Cohesive viscoelastic; replace if necessary • Low flow rates and low vacuum settings • Avoid touching or bouncing the iris • If starting pupil is small or becomes small, use iris hooks or pupil

rings

Tamsulosin Pupil with Healon V

Tamsulosin: Malyugin Ring

Summary: Misbehaving Pupils

• Old causes of intraoperative miosis (miotic agents) have been supplanted by new topical (prostaglandin analogues) and systemic agents (alpha1 analogues)

• New instruments and devices have optimized pupil control

– Pharmacologic agents – Epi-Shugarcaine – Viscoelastics – Healon V – Pupil stretchers – Beehler expanders – Iris hooks and rings

In Conclusion:

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