An Intracameral Pupil-Dilating Technique

CATARACT & REFRACTIVE SURGERY TODAY EUROPE CATARACT &REFRACTIVE SURGERY a cosmetically disfiguring pupil appearance, sometimes a cosmetically disfiguring pupil appearance, sometimes cal instruments increases markedly, and this can result in you do not have a sufficient view to ensure safety. deliver the lens nucleus or perform phacoemulsification if quent steps become more difficult. For instance, you cannot ing in the anterior lens capsule cannot be fashioned, subse sufficient diameter is not possible. When a satisfactory open pupil, performing capsulorrhexis or anterior capsulotomy of SURGICAL RISKSWITHSMALLPUPILS and presents the rationale for its use. method that I call the well before starting surgery. This article describes a reversible postoperatively. PUPIL-DILATING TECHNIQUEPUPIL-DILATING INTRACAMERALAN BY MOHAMMADIDREES,FRCS(E No devicesareneededwiththisreversiblemethod. The chances of accidentally touching the iris with surgi Among the most prominent challenges with a narrow These increased risks can be avoided if the pupil is dilated • • • end ofsurgerycausesthepupil toconstrictagain. to pupildilation. the pupil,anddilatorbecomes uninhibited, leading lidocaine causestopicalanesthesia tothesphincterof is appliedtotheentireanteriorsurfaceofiris; the advantage ofthemusclecontroliris. Injection of carbachol into the anterior chamber at the Injection ofcarbacholintothe anterior chamberatthe During thetechnique, 1%preservative-free lidocaine The Idreesintracameralpupil-dilatingtechniquetakes AT A during surgery and unfavorable outcomes during surgery and unfavorable outcomes difficult, increasing the risk of complications surgeon’s view and makes each step more is not sufficiently dilated, it obstructs the with an appropriate IOL. When the pupil safely remove the cataract and replace it pupil is necessary to allow the surgeon to In cataract surgery, a sufficiently dilated Idrees intracameral pupil-dilating technique GLANCE

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of potential complications, such as decentration and subse poorly dilating pupil. Implanting the IOL poses its own set which opens the door to other complications later. Emulsification risks damage to the posterior lens capsule, the capsular margin are increased due to poor visibility. associated with glare. Moreover, chances of damage to dilate, and vice versa. pathetic nerve system takes over and causes the pupil to parasympathetic nerve supply is paralyzed, then the sym the iris can cause the pupil to behave abnormally. If the can affect the pupil. At minimum, age-related changes in formation is common, most develop some disease that the size and shape of the pupil. the nerve supply or the muscles can cause abnormality in of the pupil under normal conditions. Any disease affecting delicate balance between these muscles determines the size the sphincter by the parasympathetic nervous system. A dilator is supplied by the sympathetic nervous system and muscle, which is responsible for constricting the pupil. The when stimulated, causes pupil dilation, and the sphincter chronic uveitis, glaucoma, or diabetes. pupil, especially in patients with pseudoexfoliation syndrome, reaction. They also may result in changing the shape of the tear, bleeding, iris damage, and severe postoperative fibrinoid are not ideal. They can cause increased risks of iris sphincter during cataract surgery and preventing intraoperative miosis Pupil to Dilate of the most common techniques are described in you musthaveanumberofapproachesatyourdisposal;some PUPIL DILATION:MECHANISMANDTECHNIQUE can create cosmesis concerns. increased postoperative inflammation and iris defects that cortical material. Additionally, iris chafing can contribute to iris prolapse into the wound, or incomplete evacuation of quent malpositioning of the IOL. It is difficult to get a sufficient red fundus reflex with a It is difficult to get a sufficient red fundus reflex with a As individuals reach the stage of life at which cataract Pupil sizeiscontrolledbytwo muscles—thedilator,which, Unfortunately, most maneuvers for enlarging the pupil In order to achieve a satisfactorily dilated pupil in every case, Operating through a small pupil can result in iris bleeding, . Getting the Getting the - - CATARACT SURGERY

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SEPTEMBER 2017 The pupil can be dilated by performing multiple smallThe pupil can be dilated by performing multiple add medications to the irrigationSome surgeons into the anteriorAccidental injection of lidocaine Dilating drops, such as 2.5% phenlyephrine or 1% 2.5% phenlyephrine Dilating drops, such as mechanical dilation.Use of an OVD can produce devices are retracting A variety of hooks, rings, and the basic concept of intracameral pupil dilation, which is pupil dilation, the basic concept of intracameral body of this article.further explained in the main available for pupil stretching and dilation. These devicesavailable for pupil stretching and dilation. time to surgery, pro removal insertion and add cost, add they stay in for the duration vide limited preset dilation to change permanent the eye, and involve risks including endo corneal the shape of the pupil and damage to the devicesthelium. In eyes with posterior synechiae, these the Perfecthave limited potential for use. Examples include Iris ProtectorPupil (Milvella), Morcher Pupil Dilator, Siepser (EagleVision). and Graether Pupil Expander (EagleVision), Sphincterotomy This approach is the pupil margin. sphincterotomies along permanentlyquite invasive. It affects the shape of the pupil of appearance unpleasant cosmetic and can result in an the pupil for the rest of the patient’s life. Fluid in Irrigation Injection Intracameral solution to dilate the pupil. The effect of this continuous can be harmful,exposure on the corneal endothelium eyes with an already low endothelial count. especially in Injection Intracameral chamber by an ophthalmologist many years ago suggested GETTING THE PUPIL PUPIL THE GETTING TO DILATE Eye Drops over some instilled by the patient tropicamide, must be In some cases, due toperiod of time preoperatively. the effect the part of the patient, improper technique on or there may be side effects related to satisfactory, is not are also useful to keep the pupilthe drops. Topical NSAIDs dilated during surgery. Viscomydriasis to duration However, the effect is usually not of sufficient stress-free surgery. allow risk- and Devices Mechanical My intracameral pupil-dilation technique may not benot may technique pupil-dilation intracameral My effective if there are dense posterior synechiae or structuralor synechiae posterior dense are there if effective pupil.or iris the of microscopic) or (gross abnormalities proceedingbefore performed is synechiolysis if However, well. work can it technique, this with

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120 The time lidocaine indicated for indicated for application of application of TO SECONDS 80 80 The greatest advantage of this technique, in my opinion, isopinion, my in technique, this of advantage greatest The The Idrees intracameral pupil-dilating method is a helpfula is method pupil-dilating intracameral Idrees The If needed, the technique can be repeated during surgery. A surgery. during repeated be can technique the needed, If An interesting and useful feature of this intracameral methodintracameral this of feature useful and interesting An Once the required time has passed, I irrigate a dilute solu dilute a irrigate I passed, has time required the Once The lidocaine causes topical anesthesia to the sphincterthe to anesthesia topical causes lidocaine The My intracameral technique for pupil dilation takes advan takes dilation pupil for technique intracameral My pupil as it affects intraoperative visualization.intraoperative affects it as pupil that it makes cataract surgery safe. As noted, we cannot safe cannot we noted, As safe. surgery cataract makes it that dilatedinsufficiently an through removal cataract perform ly experience, it is effective in patients taking medication formedication taking patients in effective is it experience, hypertension,diabetes, with those in and prostate enlarged disease. heart ischemic or technique with a valid scientific basis. In my experience, itexperience, my In basis. scientific valid a with technique oriris the in pathology structural no with patients in safe is myin Further, diameter. pupillary control that muscles the for intracameral irrigation. intracameral for ADVANTAGES AND LIMITATIONS and comes back to its normal diameter within 3 days. 3 within diameter normal its to back comes and used be can insulinsyringe an on mounted cannula 30-gauge at the end of surgery, the pupil responds to this and constrictsand this to responds pupil the surgery, of end the at ofend the at irrigated not is carbachol the If 2). (Figure again hours24 than more for dilated well remains pupil the surgery, takes place in less than 1 minute. 1 than less in place takes chamberanterior the into injected is carbachol when that, is tion of adrenaline 1:1,000. The dilution is 0.2 mL adrenalinemL 0.2 is dilution The 1:1,000. adrenaline of tion the stimulates This solution. saline balanced mL 0.8 with Thisdilation. pupil further causing iris, the muscleof dilator ing to pupil dilation. By leaving the lidocaine in place forplace in lidocaine the leaving By dilation. pupil to ing establishedwell is effect anesthetic the seconds, 120 to 80 1). (Figure step next the to proceed I before outcome regarding pupil dilation with this technique. this with dilation pupil regarding outcome lead uninhibited, becomes dilator the and pupil, the of the chamber, onto the entire anterior surface of the iris. Iiris. the of surface anterior entire the onto chamber, the isthere that found have I as minutes, 2 about for this leave satisfactorya and timing the between relationship critical a A UNIQUE APPROACH ante the enter I Once iris. the of control muscle the of tage intolidocaine preservative-free 1% irrigate I chamber, rior CATARACT SURGERY 34

CATARACT & REFRACTIVE SURGERY TODAY EUROPE CATARACT &REFRACTIVE SURGERY and measures to ensure that we start with a well-dilated view of this, cataract surgeons must take all possible steps easy, and relatively free from stress for the surgeon. In of medicolegal proceedings as well. along with mental stress for the operating surgeon and fear tions, potentially causing unsatisfactory visual outcomes can be associated with a cascade of subsequent complica and anatomic outcomes. plications and provide patients with the best possible visual allows the surgeon to effectively minimize the risk of com a minimally invasive approach to reduce surgical trauma one of the most challenging surgical procedures. Use of CONCLUSION A well-dilated pupil, by contrast, makes surgery safe, Each complication arising due to a poorly dilating pupil Cataract surgery in the presence of a small pupil remains

SEPTEMBER 2017 SEPTEMBER - - of a severe uveitis attack. also be used to break fresh posterior synechiae in the event dilated pupil for proper intraoperative manipulation. It can in vitreoretinal surgery, when the surgeon needs a well- helpful be also intracameral pupil-dilating technique can most important indication for pupil dilation, but the Idrees procedure. pupil and that the pupil remains dilated throughout the Obviously cataract surgery is the most common and n n n Mohammad Idrees, FRCS(Edin) Center, Riyadh,SaudiArabia Financial disclosure: Noneacknowledged [email protected] Consultant inOphthalmology,Aldara HospitalandMedical n Figure 2. The response Figure 2. The response adrenaline irrigation. followed by dilute irrigation of lidocaine and the time following between the pupil diameter Figure 1. The relationship IOL implantation. of the pupil at the end of carbachol and constriction intracameral irrigation of and relationship between