REVIEW URRENT C OPINION
Small pupil and cataract surgery Hassan Hashemi a,b, Mohammad A. Seyedian a, and Mehrdad Mohammadpour b
Purpose of review Presence of a small pupil is still considered a major challenge for cataract surgeons. Appropriate mydriasis and maintaining it is of paramount importance to prevent potential serious complications. Recently, more interventions and instruments are available for the cataract surgeons to deal with these challenging cases. The intention of this review is to discuss the preoperative and intraoperative considerations and techniques for cataract surgery in small pupil and related conditions and to discuss new developments in management of small pupil in femtosecond laser-assisted cataract surgery. Recent findings There are new techniques and pharmaceuticals available to cataract surgeons in the setting of small pupil. Intracameral ketorolac may soon be available to maintain mydriasis and to control pain and inflammation. Malyugin ring has been added to pupil expansion rings and has already been used for small pupil in different settings. In femtosecond laser-assisted cataract surgery, presence of a small pupil can now be managed by applying intracameral mydriatics and intraocular devices successfully. Summary Accurate preoperative examinations adjunct with intraoperative use of appropriate pharmacologic and mechanical devices can yield favorable outcomes in cataract surgery with a small pupil. Keywords femtosecond laser-assisted cataract surgery, floppy iris syndrome, iridoschisis, small pupil
INTRODUCTION WHO estimates that by 2020 more than 30 million cataract surgeries will be performed annually worldwide (website: http://www.who.int/mediacentre/ factsheets/fs214/en/). As one of the most successful operations, patient expectations are rising. With modern techniques, there is a need for direct visualization of the lens capsule on an area at least as large as the size of continuous curvilinear capsulorhexis (CCC), as well as the nucleus and epinucleus. The limiting effect of a small pupil can lead to serious sight-threatening complications such as anterior and posterior capsule tears, iris trauma, dropped nucleus or intraocular lens, cystoid macular edema, and retinal detachment [1,2]. Every cataract surgeon should be familiar with the management of small pupil, and this review aims to present a step-by-step approach and the latest in pharmacologic and surgical measures.
ETIOLOGY The incidence of small pupil is not well established and may vary by population and ethnic group. One study reported an incidence of 11% in
uncomplicated cataract surgeries [1]. In addition to iris sphincter sclerosis from aging, the most common and important causes of small pupil include pseudoexfoliation syndrome (PXF), diabetes, intraoperative floppy iris syndrome (IFIS), and iridoschisis. In PXF, pseudoexfoliative material within the iris stroma causes mechanical obstruction, which in combination with hypoxia due to vascular abnormalities, leads to limited mydriasis [3]. Diabetic patients often have abnormally small pupils that are sometimes resistant to mydriatics. Possible causes are neuropathy of the dilator muscle sympathetic innervation, and abnormalities in iris muscles and blood vessels [4]. IFIS is a triad of iris stroma billowing in response to normal irrigation a
Noor Ophthalmology Research Center, Noor Eye Hospital and Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran b
Correspondence to Hassan Hashemi, MD, Noor Ophthalmology Research Center, Noor Eye Hospital, 106 Esfandiar Blv, Valie-Asr Ave, 19686-53111 Tehran, Iran. Tel: +98 21 82400 x1607; fax: +98 21 8865 0501; e-mail: [email protected] Curr Opin Ophthalmol 2015, 26:3–9 DOI:10.1097/ICU.0000000000000116
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cataract surgery and lens implantation
KEY POINTS Small pupil is a common challenging situation, and every cataract surgeon should be familiar with strategies to minimize the possible complications and to achieve best outcomes. Pharmaceuticals, including various intracameral medications and viscoelastics, are usually the first steps in the management of a small pupil. Several iris manipulation techniques and also pupil expansion devices are now available, and every cataract surgeon should learn how to use them to overcome the small pupil problem. IFIS can cause significant complications and to prevent from these, the first priority is to anticipate IFIS and be prepared to employ compensatory surgical techniques. Many of the pharmacologic managements and surgical techniques, which can be used for small pupils in general, can also be applied in the setting of femtosecond laser-assisted cataract surgery with excellent results.
currents, tendency of the floppy iris to prolapse through the incisions, and progressive pupillary constriction. The clinical presentation varies widely from a mild form with only a fluttering iris to a more severe form with the complete triad. Even though the IFIS has been reported with the use of many medications [5], the majority of cases is related to alpha-1 antagonists, particularly tamsulosin [5,6]. A rare but important iris disorder is iridoschisis. In this condition, the iris stroma is cleaved in two portions and the anterior and posterior iris stroma separate. The anterior layer splits into strands, and the free ends float freely in the anterior chamber [7]. Other causes of small pupil include synechias, previous trauma or surgery, uveitis, and chronic miotic therapy for glaucoma.
that needs mechanical devices [9]. Therefore, a careful examination of the corneal endothelial status is important, and if suspected, central pachymetry and specular microscopy are necessary.
PREOPERATIVE PUPIL DILATION Two main groups of mydriatics are adrenergic stimulants, such as phenylephrine, that act on the iris dilator muscle and parasympatholytics, such as tropicamide and cyclopentolate, that relax the iris sphincter. To achieve maximum dilation, at least one medication from each group is needed. A common combination is phenylephrine 2.5% and tropicamide 1% [10 ]. Higher concentrations of phenylephrine may be more effective [11,12] but also pose a greater risk of systemic cardiovascular side-effects [11,13]. Miosis during cataract surgery is thought to be partly related to an increase in the concentration of prostaglandins, which can be prevented with topical NSAIDs [14]. A topical NSAID such as ketorolac is usually part of the preoperative regimen. Repeated instillation of eye drops, needed for conventional topical mydriasis can be avoided using novel approaches. One option is ocular inserts. Mydriasert (Spectrum Thea Pharmaceuticals Limited, UK) contains phenylephrine and tropicamide and can be inserted in the inferior fornix 1 h before surgery. Another strategy is to use medication-soaked pledget sponges. Both methods have shown mydriatic effects comparable with topical drops [15–17]. &&
INTRAOPERATIVE MANAGEMENT When despite the adequate use of topical mydriatics, the pupil size is still not large enough to proceed with the surgery, the surgeon needs to use some intraoperative techniques to enlarge the pupil.
PREOPERATIVE CONSIDERATIONS
Pharmaceuticals
Preoperative pupil size assessment is an important consideration. Eyes with a preoperative dilated pupil diameter of 7.0 mm or smaller are at risk for IFIS, regardless of systemic alpha-1-A adrenergic receptor antagonist treatment [8]. The status of the zonules and pseudoexfoliative material on the capsule should be evaluated. The anterior chamber depth can be a useful indirect predictor of intraoperative complications, especially in PXF; zonules are weak when the anterior chamber is very shallow or very deep [3]. Endothelial damage may be more when phacoemulsification is done in the presence of a small pupil
Usually the first step is intracameral injection of mydriatic medications, followed by viscoelastic devices.
4
www.co-ophthalmology.com
Intracameral mydriatics Intracameral mydriatics (ICM) appear to provide rapid mydriasis comparable to topical mydriatics [18,19 ], without measurable ocular or systemic sideeffects or unwanted impact on the phacoemulsification procedure [20–22]. Different concentrations of epinephrine and phenylephrine have been used with almost same effects [23]. Adding lidocaine to the ICM solution enhances the mydriatic effects and reduces &
Volume 26 Number 1 January 2015
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Small pupil and cataract surgery Hashemi et al.
FIGURE 1. Bimanual pupil stretching. The pupil is stretched in two perpendicular meridians.
patient discomfort [24–26]. Intracameral ketorolac combined with phenylephrine may soon be available and is expected to maintain mydriasis and decrease postoperative pain. The results of phase 3 clinical trial of this new ICM have been encouraging [10 ]. Because free radicals are present in intracameral surgical agents, risk of endothelial damage and toxic anterior segment syndrome must be considered when using multiple intracameral preparations in complicated cases [27]. &&
Viscoadaptive agents Further mydriasis can be achieved by injection of cohesive, high molecular weight ophthalmic viscoelastic devices (OVD) into the anterior chamber [28 ]. &&
Modifications in surgical technique When the pupil is marginally dilated, the hidden capsulorhexis margin can be guessed by scrutinizing the folded anterior capsule flap. By applying centripetal forces during capsulorhexis, one can keep the advancing CCC edge just at the pupillary margin beneath the pupil edge, while a tight rein is kept on the capsulorhexis size [29]. For marginally dilated pupils, phaco chop techniques, horizontal and vertical, are safer because emulsification is mostly done in the endolenticular space at the center of the CCC rather than the lens equator [30]. Frequent use of OVD while emulsifying the endonucleus and epinucleus is helpful and can add to surgical safety.
Pupil stretching Bimanual pupil stretching is done with two hooks, which engage two opposite points on the pupillary margin and are pushed and pulled gently in opposite directions. Stretching is usually repeated in a direction perpendicular to the initial stretch to achieve maximum possible dilation (Fig. 1). Pupil stretching can also be done one-handedly using Beehler pupil dilator (Ambler Surgical Corp, USA). This instrument has three micro-fingers and a hook and stretches the pupil in four asymmetrical quadrants. Both stretch techniques can be performed in less than 1 min and are thus time-saving methods. But, compared with pupil dilating devices, the final pupil size is usually smaller and some intraoperative miosis can be expected [31]. Multiple sphincterotomies Another iris manipulation technique is to produce multiple sphincterotomies. In this technique, an intraocular scissors are used to produce eight equally distanced small-size sphincterotomies (Fig. 2). After completion, a hook is used to stretch the pupil slowly to the root of the iris at each sphincterotomy site. Because sphincterotomies are produced selectively, the final pupil size is larger, there are no uncontrolled sphincter microruptures, and the final pupil appearance and function is more acceptable compared to bimanual stretching [32]. Pupil stretching and sphincterotomy techniques should be avoided in the presence of IFIS and iridoschisis because the risk of iris prolapse and aspiration in the phaco tip is increased.
Iris stretching and sphincterotomies Should the above interventions fail, iris surgery techniques or pupil dilating devices should be considered.
Iris retracting hooks Although more costly and time consuming compared to stretch techniques [31], iris hooks are safe
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
5
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cataract surgery and lens implantation
FIGURE 3. Iris retractor hooks in place. Note the subincisional position of the fifth hook.
FIGURE 2. Multiple sphincterotomies An intraocular scissors is used to produced eight sphincterotomies. Adapted from [33].
and have a relatively easy learning curve. Indications include small pupil, IFIS, and iridoschisis, but they can also be used for capsular support in subluxated lenses [33]. Iris hooks are placed through side ports, and their proper positioning is crucial to prevent possible complications such as raised iris platform between the hooks and iris prolapse. Side ports should be placed parallel to the iris plane and as posteriorly as possible. With proper placement, the possibility of iris prolapse through the main incision is very low. Should this happen, it can be prevented by placing a fifth hook subincisionally (Fig. 3).
margin and prevent iris tearing or damage. All these rings have been used successfully in the management of small pupils and also in the setting of IFIS and iridoschisis [31,32,34]. The Malyugin Ring (MicroSurgical Technology, USA), a more recent addition, is made of polypropylene with the thin profile of an intraocular lens haptic. This makes it easier to insert without corneal contact and safer to manipulate inside the eye, and it does not get in the way during surgery. The loading and injection system is also disposable and relatively simple. Once injected into the anterior chamber, its four circular coils engage the pupil edge to expand it [35 ] (Fig. 4). Available sizes are 6.25 mm, universal for almost any case with &
Pupil expansion rings Pupil expanders including Graether 2000 pupilexpander system (Eagle Vision, Inc., USA), Morcher pupil dilator (Morcher, Germany), and Perfect Pupil (Milvella Limited, Australia) have been discussed in details previously [34]. They are made from different materials with different flexibilities, but all can be inserted through the main incision. They capture the entire iris sphincter, so in addition to continuous dilation, they also protect the iris sphincter 6
www.co-ophthalmology.com
FIGURE 4. Malyugin ring is used to dilate the pupil in a case of subluxated lens. Volume 26 Number 1 January 2015
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Small pupil and cataract surgery Hashemi et al.
small pupil, and a larger 7.0 mm, which is useful in IFIS. Because the ring is so thin and light, it is still mobile enough to allow the iris to occasionally prolapse to the side port incision, however, the pupil cannot constrict. The Malyugin ring cannot be inserted in very small pupils, and in these situations, it would be necessary to dilate the pupil by another technique before ring insertion. This ring has been used successfully in IFIS and iridoschisis and also in femtosecond laser-assisted cataract surgery [8,36,37 ]. There are no published data comparing different expansion rings. Each of these rings has its own benefits and drawbacks and also learning curve. The selection of one particular ring over the other would be on the basis of availability, cost, and surgeon familiarity. &
INTRAOPERATIVE FLOPPY IRIS SYNDROME Should the surgeon not be aware and not take appropriate surgical measures, IFIS can be associated with serious ophthalmic adverse events [9,38,39].
intracameral phenylephrine was evaluated in patients receiving tamsulosin and undergoing cataract surgery [45]. Although 88.09% in the control group showed signs of IFIS, there were no such signs in eyes receiving intracameral phenylephrine. In the control group, the condition was successfully reverted after intracameral phenylephrine administration. The use of lidocaine in intracameral solutions is also important as it relaxes the sphincter muscle. Iris hooks and pupil expander rings Iris hooks and all pupil expander devices have been used with success in IFIS [32,35 ,46 ]. These devices are indicated in patients who do not react well enough to pharmacological methods. &
&&
Modifications in surgical technique The first priority is to produce a properly made incision in the clear cornea. Both the main incision and the paracentesis should be long enough and as far from the iris root as possible to reduce the possibility of iris prolapse. Generally, the use of soft fluidics is recommended to reduce iris wobbling and increase the permanence time of the high-density viscoelastic [46 ]. In case of soft or moderate nuclear densities, bimanual phaco techniques can be superior to coaxial techniques [32,47]. The small incision size reduces the risk of iris prolapse. In bimanual technique, by separating irrigation and aspiration, the irrigation flow can be kept above the iris and, therefore, reduce its tendency toward herniation. The use of high-density viscoelastic such as 2.3% hyaluronate (Healon 5, Abbott Medical Optics, USA) is also useful for stabilizing the iris [32,48]. Healon 5 keeps the pupil dilated and prevents iris prolapse by exerting direct backward pressure on it. &&
Treatment Approach to the management of IFIS can be divided into several steps including pre and intraoperative measures. Suspension of the causative medication In addition to functional changes, tamsulosin induces atrophy of the iris and pupil dilator muscle [40,41], and the syndrome can appear even years after discontinuing the drug. Accordingly, suspending treatment with tamsulosin is inefficient most of the time. Preoperative topical atropine The use of preoperative atropine has been reported to be effective in reducing IFIS severity [42], especially when combined with intracameral phenylephrine [43]. Atropine seems to improve initial mydriasis, even though the intensity of the syndrome is not reduced. Intracameral adrenergic agonists As the inhibition is theoretically reversible, the injection of phenylephrine or epinephrine in high concentrations in the anterior chamber should displace tamsulosin from alpha receptors. This is probably the most efficient measure after implanting mechanical devices [43,44]. In a prospective randomized comparative study, the efficacy of
Awareness of intraoperative floppy iris syndrome Preoperative identification of patients on alpha-1 blockers is important to be prepared with management strategies. When experienced surgeons anticipate IFIS and employ compensatory surgical techniques, complication rates are low and the visual outcomes can be excellent in patients with a history of tamsulosin use [49].
SMALL PUPIL AND FEMTOSECOND LASER-ASSISTED CATARACT SURGERY Femtosecond laser cataract surgery systems require optical imaging, targeting, and laser delivery, and a small or irregular pupil can impede anterior capsulotomy and nucleus fragmentation. When the pupil
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
7
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cataract surgery and lens implantation
size is smaller than the intended capsulotomy size despite intense topical application of mydriatics, the surgeon faces a major challenge at the start of the surgery. Furthermore, the immediate effects of lens laser treatment are different from conventional phacoemulsification. A postlaser treatment miosis means a narrow pupil after laser pretreatment, which is due to progressive miosis in a previously proper size pupil after the completion of laser treatment. This can occur in approximately 5–32% of all cases [12,37 ,50,51]. Immediately after femtosecond laser treatment, the aqueous humor shows a significant rise in prostaglandin E2 and total prostaglandin, which can be responsible for the miosis [52 ]. &
&
Laser-induced miosis Preoperative application of topical NSAIDs can prevent intraoperative miosis during phacoemulsification [14]. The incidence of laser-induced miosis can be decreased to 1% with NSAID pretreatment [53]. In a series of patients, the 9.5% incidence of postlaser pupillary constriction was decreased to 1.23% by additional instillation of a drop of 10% phenylephrine immediately after laser treatment [12]. It seems that the longer the elapsed time between laser pretreatment and commencing intraocular surgery, the smaller the pupils become. It is recommended to start lens removal within 15 min after laser pretreatment [54]. In cases of laser-induced miosis, slow injection of intracameral epinephrine after opening of the laser-assisted incisions would be very helpful to enlarge the pupil again.
Small pupil before the application of laser treatment Anterior chamber integrity is necessary for successful laser application. Any penetration for intracameral injections or inserting pupil dilating devices may result in wound leakage and anterior chamber instability owing to an increase in intraocular pressure (IOP) during suction and corneal applanation. Intracameral mydriatics In a series of 40 eyes with small pupils, intracameral injection of epinephrine was sufficient to achieve a pupil larger than 5.5 mm in 7% of the eyes [28 ]. Kankariya et al. [55] reported results of epinephrine 0.025% and lidocaine 0.75% injection through a 0.8-mm corneal paracentesis, followed by introduction of viscoelastic to achieve further pupillary dilatation and maintain anterior chamber stability during subsequent femtosecond laser pretreatment. In both reports, anterior chamber penetration &&
8
www.co-ophthalmology.com
before laser pretreatment was feasible for the management of small pupils. Viscomydriasis Additional injection of OVD can further dilate the pupil in a considerable proportion of patients [28 ]. This can also result in further anterior chamber stabilization during suction and IOP rise [55]. &&
Iris retractor hooks and Malyugin ring Iris retractor hooks have been used successfully to dilate the pupil without interfering with the docking process [37 ]. Malyugin ring has also been used to keep the pupil dilated [28 ,37 ,55–57]. In all reports, ring insertion was through a 1.8–2.75-mm clear corneal incision without any evidence of anterior chamber instability during laser pretreatment. &
&&
&
CONCLUSION Phacoemulsification in the presence of a small pupil continues to be a challenging situation. Innovations in surgical instruments and techniques may improve patient safety and suggest new treatment paradigms. Preoperative assessment and identification of patients with small pupils or at risk for miosis is important to take compensatory measures to keep the complication rate as low as possible and to achieve excellent visual outcomes. Acknowledgements The article has not been presented in a meeting. The authors did not receive any financial support from any public or private source. The authors have no financial or proprietary interest in a product, method, or material described herein. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Hashemi H, Mohammadpour M, Jabbarvand M, et al. Incidence of and risk factors for vitreous loss in resident-performed phacoemulsification surgery. J Cataract Refract Surg 2013; 39:1377–1382. 2. Chen M, Lamattina KC, Patrianakos T, Dwarakanathan S. Complication rate of posterior capsule rupture with vitreous loss during phacoemulsification at a Hawaiian cataract surgical center: a clinical audit. Clin Ophthalmol 2014; 8:375–378. 3. Belovay GW, Varma DK, Ahmed II. Cataract surgery in pseudoexfoliation syndrome. Curr Opin Ophthalmol 2010; 21:25–34. 4. Negi A, Vernon SA. An overview of the eye in diabetes. J R Soc Med 2003; 96:266–272. 5. AltiaylikOzer P, Altiparmak UE, Unlu N, et al. Intraoperative floppy-iris syndrome: comparison of tamsulosin and drugs other than alpha antagonists. Curr Eye Res 2013; 38:480–486.
Volume 26 Number 1 January 2015
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Small pupil and cataract surgery Hashemi et al. 6. Chang DF, Campbell JR, Colin J, et al. Prospective masked comparison of intraoperative floppy iris syndrome severity with tamsulosin versus alfuzosin. Ophthalmology 2014; 121:829–834. 7. Gogaki E, Tsolaki F, Tiganita S, et al. Iridoschisis: case report and review of the literature. Clin Ophthalmol 2011; 5:381–384. 8. Chang DF. Use of malyugin pupil expansion device for intraoperative floppyiris syndrome: results in 30 consecutive cases. J Cataract Refract Surg 2008; 34:835–841. 9. Storr-Paulsen A, Jørgensen JS, Norregaard JC, Thulesen J. Corneal endothelial cell changes after cataract surgery in patients on systemic sympathetic a-1a antagonist medication (tamsulosin). Acta Ophthalmol 2014; 92:359– 363. 10. Grob SR, Gonzalez-Gonzalez LA, Daly MK. Management of mydriasis and && pain in cataract and intraocular lens surgery: review of current medications and future directions. Clin Ophthalmol 2014; 8:1281–1289. This article is a review on the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control during cataract surgery. 11. Suwan-Apichon O, Ratanapakorn T, Panjaphongse R, et al. 2.5% and 10% phenylephrine for mydriasis in diabetic patients with darkly pigmented irides. J Med Assoc Thai 2010; 93:467–473. 12. Roberts TV, Lawless M, Bali SJ, et al. Surgical outcomes and safety of femtosecond laser cataract surgery: a prospective study of 1500 consecutive cases. Ophthalmology 2013; 120:227–233. 13. Kauffmann S, Commun F, Schoeffler P, et al. Cardiovascular adverse effects due to phenylephrine eye drops in ophthalmic surgery. Ann Fr Anesth Reanim 2013; 32:112–114. 14. Joshi RS. Preoperative use of the topical steroidal and nonsteroidal antiinflammatory agents to maintain intra-operative mydriasis during cataract surgery. Indian J Ophthalmol 2013; 61:246–247. 15. Torro´n C, Calvo P, Ruiz-Moreno O, et al. Use of a new ocular insert versus conventional mydriasis in cataract surgery. Biomed Res Int 2013; 2013:849349. 16. Weddle C, Thomas N, Dienemann J. Improved pupil dilation with medicationsoaked pledget sponges. AORN J 2013; 98:131–143. 17. Hargitai J, Vezendi L, Vigstrup J, et al. Comparing the efficacy of mydriatic cocktail-soaked sponge and conventional pupil dilation in patients using tamsulosin: a randomized controlled trial. BMC Ophthalmol 2013; 13:83. 18. Gupta SK, Kumar A, Agarwal S, et al. Phacoemulsification without preoperative topical mydriatics: induction and sustainability of mydriasis with intracameral mydriatic solution. Indian J Ophthalmol 2014; 62:333–336. 19. Lundqvist O, Koskela T, Behndig A. A paired comparison of intracameral & mydriatics in refractive lens exchange surgery. Acta Ophthalmol 2014; 92:482–485. A randomized study to compare the efficacy and intraoperative safety of intracameral and topical mydriatics. 20. Williams GS, Radwan M, Kadare S, et al. The short to medium-term risks of intracameral phenylephrine. Middle East Afr J Ophthalmol 2012; 19:357– 360. 21. Ba¨ckstro¨m G, Lundberg B, Behndig A. Intracameral acetylcholine effectively contracts pupils after dilatation with intracameral mydriatics. Acta Ophthalmol 2013; 91:123–126. 22. Lundberg B, Behndig A. Intracameral mydriatics in phacoemulsification cataract surgery: a 6-year follow-up. Acta Ophthalmol 2013; 91:243–246. 23. Myers WG, Shugar JK. Optimizing the intracameral dilation regimen for cataract surgery: prospective randomized comparison of 2 solutions. J Cataract Refract Surg 2009; 35:273–276. 24. Ezra DG, Nambiar A, Allan BD. Supplementary intracameral lidocaine for phacoemulsification under topical anesthesia. A meta-analysis of randomized controlled trials. Ophthalmology 2008; 115:455–487. 25. Nikeghbali A, Falavarjani KG, Kheirkhah A. Pupil dilation with intracameral lidocaine during phacoemulsification: benefits for the patient and surgeon. Indian J Ophthalmol 2008; 56:63–64. 26. Lundberg B, Behndig A. Separate and additive mydriatic effects of lidocaine hydrochloride, phenylephrine, and cyclopentolate after intracameral injection. J Cataract Refract Surg 2008; 34:280–283. 27. Lockington D, Macdonald EC, Young D, et al. Presence of free radicals in intracameral agents commonly used during cataract surgery. Br J Ophthalmol 2010; 94:1674–1677. 28. Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Femtosecond laser&& assisted cataract surgery in eyes with a small pupil. J Cataract Refract Surg 2013; 39:1314–1320. A step-by-step approach to the management of small pupil in the setting of laserassisted cataract surgery. 29. Mohammadpour M, Erfanian R, Karim N. Capsulorhexis: pearls and pitfalls. Saudi J Ophthalmol 2012; 26:33–40. 30. Chang DF. Why learn chopping? In: Chang DF, editor. Phaco chop and advanced phaco techniques. New Jersey: Slack Inc; 2013. pp. 3–11. 31. Akman A, Yilmaz G, Oto S, et al. Comparison of various pupil dilatation methods for phacoemulsification in eyes with a small pupil secondary to pseudoexfoliation. Ophthalmology 2004; 111:1693–1698.
32. Fine IH, Packer M, Hoffman RS. Phacoemulsification in the presence of a small pupil. In: Steinert RF, editor. Cataract surgery. Saunders: Elsevier Inc; 2010. pp. 245–258. 33. Kopsachilis N, Carifi G. Phacoemulsification using 8 flexible iris hooks in a patient with a short eye, small pupil, and phacodonesis. J Cataract Refract Surg 2014; 40:1408–1411. 34. Goldman JM, Karp CL. Adjunct devices for managing challenging cases in cataract surgery: pupil expansion and stabilization of the capsular bag. Curr Opin Ophthalmol 2007; 18:44–51. 35. Wilczynski M, Wierzchowski T, Synder A, Omulecki W. Results of phacoe& mulsification with Malyugin ring in comparison with manual iris stretching with hooks in eyes with narrow pupil. Eur J Ophthalmol 2013; 23:196–201. This article compares the results of a new pupil expansion device, Malyugin ring, with manual pupillary stretching with hooks. 36. Wilczynski M, Kucharczyk M. Phacoemulsification with Malyugin ring in an eye with iridoschisis, narrow pupil, anterior and posterior synechiae: case report. Eur J Ophthalmol 2013; 23:909–912. 37. Dick HB, Schultz T. Laser-assisted cataract surgery in small pupils using & mechanical dilation devices. J Refract Surg 2013; 29:858–862. Use of a new pupil expansion device for the management of small pupil in laserassisted cataract surgery. 38. Bell CM, Hatch WV, Fischer HD, et al. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA 2009; 301:1991–1996. 39. Haridas A, Syrimi M, Al-Ahmar B, et al. Intraoperative floppy iris syndrome (IFIS) in patients receiving tamsulosin or doxazosin-a UK-based comparison of incidence and complication rates. Graefes Arch Clin Exp Ophthalmol 2013; 251:1541–1545. 40. Tufan HA, Gencer B, Kara S, et al. Alterations in iris structure and pupil size related to alpha-1 adrenergic receptor antagonists use: implications for floppy iris syndrome. J Ocul Pharmacol Ther 2013; 29:410–413. 41. Shtein RM, Hussain MT, Cooney TM, et al. Effect of tamsulosin on iris vasculature and morphology. J Cataract Refract Surg 2014; 40:793–798. 42. Masket S, Belani S. Combined preoperative topical atropine sulfate 1% and intracameral nonpreserved epinephrine hydrochloride 1:4000 [corrected] for management of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2007; 33:580–582. 43. Perez-Silguero D, Ramallo-Farina Y, Perez-Silguero MA, et al. Comparison of the effectiveness of two different pharmacologic approaches to prevent intraoperative floppy iris syndrome. Arch Soc Esp Oftalmol 2009; 84:549–556. 44. Carifi G, Kopsachilis N. Alpha-1 adrenergic agonists for the prevention of floppy iris syndrome. Ophthalmology 2013; 120:e43. 45. Lorente R, de Rojas V, Va´zquez de Parga P, et al. Intracameral phenylephrine 1.5% for prophylaxis against intraoperative floppy iris syndrome: prospective, randomized fellow eye study. Ophthalmology 2012; 119:2053–2058. 46. Martı´n-Moro JG, Negrete FM, Escobar IL, Miguel YF. Intraoperative floppy-iris && syndrome. Arch Soc Esp Oftalmol 2013; 88:64–76. A comprehensive review on IFIS. 47. Lockington D, Gavin MP. Intraoperative floppy-iris syndrome: role of the bimanual approach. J Cataract Refract Surg 2009; 35:964. 48. Jhanji V, Sharma N, Vajpayee RB. Management of intraoperative miosis during pediatric cataract surgery using Healon 5. Middle East Afr J Ophthalmol 2011; 18:55–57. 49. Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (flomax). Ophthalmology 2007; 114:957–964. 50. Bali SJ, Hodge C, Lawless M, et al. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012; 119:891–899. 51. Nagy ZZ, Takacs AI, Filkorn T, et al. Complications of femtosecond laserassisted cataract surgery. J Cataract Refract Surg 2014; 40:20–28. 52. Schultz T, Joachim SC, Kuehn M, Dick HB. Changes in prostaglandin levels in & patients undergoing femtosecond laser-assisted cataract surgery. J Refract Surg 2013; 29:742–747. This study investigates the intraocular prostaglandin concentrations after femtosecond laser treatment and the potential relationship to miosis. 53. Dick HB, Gerste RD, Schultz T. Laser cataract surgery: curse of the small pupil. J Refract Surg 2013; 29:662. 54. Passut J. Panelists answer questions from femto for cataract webinar. Webinar presented at: ASCRS Eyeworld; September 2011. http://www.eye world.org/article.php?sid=6036&strict=0&morphologic=0&query. 55. Kankariya VP, Diakonis VF, Yoo SH, et al. Management of small pupils in femtosecond-assisted cataract surgery pretreatment. Ophthalmology 2013; 120:2359–2360. 56. Kra´nitz K, Taka´cs AI, Gyenes A, et al. Femtosecond laser-assisted cataract surgery in management of phacomorphic glaucoma. J Refract Surg 2013; 29:645–648. 57. Roberts TV, Lawless M, Hodge C. Laser-assisted cataract surgery following insertion of a pupil expander for management of complex cataract and small irregular pupil. J Cataract Refract Surg 2013; 39:1921–1924.
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
9
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Small pupil and cataract surgery Hassan Hashemi a,b, Mohammad A. Seyedian a, and Mehrdad Mohammadpour b
Purpose of review Presence of a small pupil is still considered a major challenge for cataract surgeons. Appropriate mydriasis and maintaining it is of paramount importance to prevent potential serious complications. Recently, more interventions and instruments are available for the cataract surgeons to deal with these challenging cases. The intention of this review is to discuss the preoperative and intraoperative considerations and techniques for cataract surgery in small pupil and related conditions and to discuss new developments in management of small pupil in femtosecond laser-assisted cataract surgery. Recent findings There are new techniques and pharmaceuticals available to cataract surgeons in the setting of small pupil. Intracameral ketorolac may soon be available to maintain mydriasis and to control pain and inflammation. Malyugin ring has been added to pupil expansion rings and has already been used for small pupil in different settings. In femtosecond laser-assisted cataract surgery, presence of a small pupil can now be managed by applying intracameral mydriatics and intraocular devices successfully. Summary Accurate preoperative examinations adjunct with intraoperative use of appropriate pharmacologic and mechanical devices can yield favorable outcomes in cataract surgery with a small pupil. Keywords femtosecond laser-assisted cataract surgery, floppy iris syndrome, iridoschisis, small pupil
INTRODUCTION WHO estimates that by 2020 more than 30 million cataract surgeries will be performed annually worldwide (website: http://www.who.int/mediacentre/ factsheets/fs214/en/). As one of the most successful operations, patient expectations are rising. With modern techniques, there is a need for direct visualization of the lens capsule on an area at least as large as the size of continuous curvilinear capsulorhexis (CCC), as well as the nucleus and epinucleus. The limiting effect of a small pupil can lead to serious sight-threatening complications such as anterior and posterior capsule tears, iris trauma, dropped nucleus or intraocular lens, cystoid macular edema, and retinal detachment [1,2]. Every cataract surgeon should be familiar with the management of small pupil, and this review aims to present a step-by-step approach and the latest in pharmacologic and surgical measures.
ETIOLOGY The incidence of small pupil is not well established and may vary by population and ethnic group. One study reported an incidence of 11% in
uncomplicated cataract surgeries [1]. In addition to iris sphincter sclerosis from aging, the most common and important causes of small pupil include pseudoexfoliation syndrome (PXF), diabetes, intraoperative floppy iris syndrome (IFIS), and iridoschisis. In PXF, pseudoexfoliative material within the iris stroma causes mechanical obstruction, which in combination with hypoxia due to vascular abnormalities, leads to limited mydriasis [3]. Diabetic patients often have abnormally small pupils that are sometimes resistant to mydriatics. Possible causes are neuropathy of the dilator muscle sympathetic innervation, and abnormalities in iris muscles and blood vessels [4]. IFIS is a triad of iris stroma billowing in response to normal irrigation a
Noor Ophthalmology Research Center, Noor Eye Hospital and Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran b
Correspondence to Hassan Hashemi, MD, Noor Ophthalmology Research Center, Noor Eye Hospital, 106 Esfandiar Blv, Valie-Asr Ave, 19686-53111 Tehran, Iran. Tel: +98 21 82400 x1607; fax: +98 21 8865 0501; e-mail: [email protected] Curr Opin Ophthalmol 2015, 26:3–9 DOI:10.1097/ICU.0000000000000116
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cataract surgery and lens implantation
KEY POINTS Small pupil is a common challenging situation, and every cataract surgeon should be familiar with strategies to minimize the possible complications and to achieve best outcomes. Pharmaceuticals, including various intracameral medications and viscoelastics, are usually the first steps in the management of a small pupil. Several iris manipulation techniques and also pupil expansion devices are now available, and every cataract surgeon should learn how to use them to overcome the small pupil problem. IFIS can cause significant complications and to prevent from these, the first priority is to anticipate IFIS and be prepared to employ compensatory surgical techniques. Many of the pharmacologic managements and surgical techniques, which can be used for small pupils in general, can also be applied in the setting of femtosecond laser-assisted cataract surgery with excellent results.
currents, tendency of the floppy iris to prolapse through the incisions, and progressive pupillary constriction. The clinical presentation varies widely from a mild form with only a fluttering iris to a more severe form with the complete triad. Even though the IFIS has been reported with the use of many medications [5], the majority of cases is related to alpha-1 antagonists, particularly tamsulosin [5,6]. A rare but important iris disorder is iridoschisis. In this condition, the iris stroma is cleaved in two portions and the anterior and posterior iris stroma separate. The anterior layer splits into strands, and the free ends float freely in the anterior chamber [7]. Other causes of small pupil include synechias, previous trauma or surgery, uveitis, and chronic miotic therapy for glaucoma.
that needs mechanical devices [9]. Therefore, a careful examination of the corneal endothelial status is important, and if suspected, central pachymetry and specular microscopy are necessary.
PREOPERATIVE PUPIL DILATION Two main groups of mydriatics are adrenergic stimulants, such as phenylephrine, that act on the iris dilator muscle and parasympatholytics, such as tropicamide and cyclopentolate, that relax the iris sphincter. To achieve maximum dilation, at least one medication from each group is needed. A common combination is phenylephrine 2.5% and tropicamide 1% [10 ]. Higher concentrations of phenylephrine may be more effective [11,12] but also pose a greater risk of systemic cardiovascular side-effects [11,13]. Miosis during cataract surgery is thought to be partly related to an increase in the concentration of prostaglandins, which can be prevented with topical NSAIDs [14]. A topical NSAID such as ketorolac is usually part of the preoperative regimen. Repeated instillation of eye drops, needed for conventional topical mydriasis can be avoided using novel approaches. One option is ocular inserts. Mydriasert (Spectrum Thea Pharmaceuticals Limited, UK) contains phenylephrine and tropicamide and can be inserted in the inferior fornix 1 h before surgery. Another strategy is to use medication-soaked pledget sponges. Both methods have shown mydriatic effects comparable with topical drops [15–17]. &&
INTRAOPERATIVE MANAGEMENT When despite the adequate use of topical mydriatics, the pupil size is still not large enough to proceed with the surgery, the surgeon needs to use some intraoperative techniques to enlarge the pupil.
PREOPERATIVE CONSIDERATIONS
Pharmaceuticals
Preoperative pupil size assessment is an important consideration. Eyes with a preoperative dilated pupil diameter of 7.0 mm or smaller are at risk for IFIS, regardless of systemic alpha-1-A adrenergic receptor antagonist treatment [8]. The status of the zonules and pseudoexfoliative material on the capsule should be evaluated. The anterior chamber depth can be a useful indirect predictor of intraoperative complications, especially in PXF; zonules are weak when the anterior chamber is very shallow or very deep [3]. Endothelial damage may be more when phacoemulsification is done in the presence of a small pupil
Usually the first step is intracameral injection of mydriatic medications, followed by viscoelastic devices.
4
www.co-ophthalmology.com
Intracameral mydriatics Intracameral mydriatics (ICM) appear to provide rapid mydriasis comparable to topical mydriatics [18,19 ], without measurable ocular or systemic sideeffects or unwanted impact on the phacoemulsification procedure [20–22]. Different concentrations of epinephrine and phenylephrine have been used with almost same effects [23]. Adding lidocaine to the ICM solution enhances the mydriatic effects and reduces &
Volume 26 Number 1 January 2015
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Small pupil and cataract surgery Hashemi et al.
FIGURE 1. Bimanual pupil stretching. The pupil is stretched in two perpendicular meridians.
patient discomfort [24–26]. Intracameral ketorolac combined with phenylephrine may soon be available and is expected to maintain mydriasis and decrease postoperative pain. The results of phase 3 clinical trial of this new ICM have been encouraging [10 ]. Because free radicals are present in intracameral surgical agents, risk of endothelial damage and toxic anterior segment syndrome must be considered when using multiple intracameral preparations in complicated cases [27]. &&
Viscoadaptive agents Further mydriasis can be achieved by injection of cohesive, high molecular weight ophthalmic viscoelastic devices (OVD) into the anterior chamber [28 ]. &&
Modifications in surgical technique When the pupil is marginally dilated, the hidden capsulorhexis margin can be guessed by scrutinizing the folded anterior capsule flap. By applying centripetal forces during capsulorhexis, one can keep the advancing CCC edge just at the pupillary margin beneath the pupil edge, while a tight rein is kept on the capsulorhexis size [29]. For marginally dilated pupils, phaco chop techniques, horizontal and vertical, are safer because emulsification is mostly done in the endolenticular space at the center of the CCC rather than the lens equator [30]. Frequent use of OVD while emulsifying the endonucleus and epinucleus is helpful and can add to surgical safety.
Pupil stretching Bimanual pupil stretching is done with two hooks, which engage two opposite points on the pupillary margin and are pushed and pulled gently in opposite directions. Stretching is usually repeated in a direction perpendicular to the initial stretch to achieve maximum possible dilation (Fig. 1). Pupil stretching can also be done one-handedly using Beehler pupil dilator (Ambler Surgical Corp, USA). This instrument has three micro-fingers and a hook and stretches the pupil in four asymmetrical quadrants. Both stretch techniques can be performed in less than 1 min and are thus time-saving methods. But, compared with pupil dilating devices, the final pupil size is usually smaller and some intraoperative miosis can be expected [31]. Multiple sphincterotomies Another iris manipulation technique is to produce multiple sphincterotomies. In this technique, an intraocular scissors are used to produce eight equally distanced small-size sphincterotomies (Fig. 2). After completion, a hook is used to stretch the pupil slowly to the root of the iris at each sphincterotomy site. Because sphincterotomies are produced selectively, the final pupil size is larger, there are no uncontrolled sphincter microruptures, and the final pupil appearance and function is more acceptable compared to bimanual stretching [32]. Pupil stretching and sphincterotomy techniques should be avoided in the presence of IFIS and iridoschisis because the risk of iris prolapse and aspiration in the phaco tip is increased.
Iris stretching and sphincterotomies Should the above interventions fail, iris surgery techniques or pupil dilating devices should be considered.
Iris retracting hooks Although more costly and time consuming compared to stretch techniques [31], iris hooks are safe
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
5
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cataract surgery and lens implantation
FIGURE 3. Iris retractor hooks in place. Note the subincisional position of the fifth hook.
FIGURE 2. Multiple sphincterotomies An intraocular scissors is used to produced eight sphincterotomies. Adapted from [33].
and have a relatively easy learning curve. Indications include small pupil, IFIS, and iridoschisis, but they can also be used for capsular support in subluxated lenses [33]. Iris hooks are placed through side ports, and their proper positioning is crucial to prevent possible complications such as raised iris platform between the hooks and iris prolapse. Side ports should be placed parallel to the iris plane and as posteriorly as possible. With proper placement, the possibility of iris prolapse through the main incision is very low. Should this happen, it can be prevented by placing a fifth hook subincisionally (Fig. 3).
margin and prevent iris tearing or damage. All these rings have been used successfully in the management of small pupils and also in the setting of IFIS and iridoschisis [31,32,34]. The Malyugin Ring (MicroSurgical Technology, USA), a more recent addition, is made of polypropylene with the thin profile of an intraocular lens haptic. This makes it easier to insert without corneal contact and safer to manipulate inside the eye, and it does not get in the way during surgery. The loading and injection system is also disposable and relatively simple. Once injected into the anterior chamber, its four circular coils engage the pupil edge to expand it [35 ] (Fig. 4). Available sizes are 6.25 mm, universal for almost any case with &
Pupil expansion rings Pupil expanders including Graether 2000 pupilexpander system (Eagle Vision, Inc., USA), Morcher pupil dilator (Morcher, Germany), and Perfect Pupil (Milvella Limited, Australia) have been discussed in details previously [34]. They are made from different materials with different flexibilities, but all can be inserted through the main incision. They capture the entire iris sphincter, so in addition to continuous dilation, they also protect the iris sphincter 6
www.co-ophthalmology.com
FIGURE 4. Malyugin ring is used to dilate the pupil in a case of subluxated lens. Volume 26 Number 1 January 2015
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Small pupil and cataract surgery Hashemi et al.
small pupil, and a larger 7.0 mm, which is useful in IFIS. Because the ring is so thin and light, it is still mobile enough to allow the iris to occasionally prolapse to the side port incision, however, the pupil cannot constrict. The Malyugin ring cannot be inserted in very small pupils, and in these situations, it would be necessary to dilate the pupil by another technique before ring insertion. This ring has been used successfully in IFIS and iridoschisis and also in femtosecond laser-assisted cataract surgery [8,36,37 ]. There are no published data comparing different expansion rings. Each of these rings has its own benefits and drawbacks and also learning curve. The selection of one particular ring over the other would be on the basis of availability, cost, and surgeon familiarity. &
INTRAOPERATIVE FLOPPY IRIS SYNDROME Should the surgeon not be aware and not take appropriate surgical measures, IFIS can be associated with serious ophthalmic adverse events [9,38,39].
intracameral phenylephrine was evaluated in patients receiving tamsulosin and undergoing cataract surgery [45]. Although 88.09% in the control group showed signs of IFIS, there were no such signs in eyes receiving intracameral phenylephrine. In the control group, the condition was successfully reverted after intracameral phenylephrine administration. The use of lidocaine in intracameral solutions is also important as it relaxes the sphincter muscle. Iris hooks and pupil expander rings Iris hooks and all pupil expander devices have been used with success in IFIS [32,35 ,46 ]. These devices are indicated in patients who do not react well enough to pharmacological methods. &
&&
Modifications in surgical technique The first priority is to produce a properly made incision in the clear cornea. Both the main incision and the paracentesis should be long enough and as far from the iris root as possible to reduce the possibility of iris prolapse. Generally, the use of soft fluidics is recommended to reduce iris wobbling and increase the permanence time of the high-density viscoelastic [46 ]. In case of soft or moderate nuclear densities, bimanual phaco techniques can be superior to coaxial techniques [32,47]. The small incision size reduces the risk of iris prolapse. In bimanual technique, by separating irrigation and aspiration, the irrigation flow can be kept above the iris and, therefore, reduce its tendency toward herniation. The use of high-density viscoelastic such as 2.3% hyaluronate (Healon 5, Abbott Medical Optics, USA) is also useful for stabilizing the iris [32,48]. Healon 5 keeps the pupil dilated and prevents iris prolapse by exerting direct backward pressure on it. &&
Treatment Approach to the management of IFIS can be divided into several steps including pre and intraoperative measures. Suspension of the causative medication In addition to functional changes, tamsulosin induces atrophy of the iris and pupil dilator muscle [40,41], and the syndrome can appear even years after discontinuing the drug. Accordingly, suspending treatment with tamsulosin is inefficient most of the time. Preoperative topical atropine The use of preoperative atropine has been reported to be effective in reducing IFIS severity [42], especially when combined with intracameral phenylephrine [43]. Atropine seems to improve initial mydriasis, even though the intensity of the syndrome is not reduced. Intracameral adrenergic agonists As the inhibition is theoretically reversible, the injection of phenylephrine or epinephrine in high concentrations in the anterior chamber should displace tamsulosin from alpha receptors. This is probably the most efficient measure after implanting mechanical devices [43,44]. In a prospective randomized comparative study, the efficacy of
Awareness of intraoperative floppy iris syndrome Preoperative identification of patients on alpha-1 blockers is important to be prepared with management strategies. When experienced surgeons anticipate IFIS and employ compensatory surgical techniques, complication rates are low and the visual outcomes can be excellent in patients with a history of tamsulosin use [49].
SMALL PUPIL AND FEMTOSECOND LASER-ASSISTED CATARACT SURGERY Femtosecond laser cataract surgery systems require optical imaging, targeting, and laser delivery, and a small or irregular pupil can impede anterior capsulotomy and nucleus fragmentation. When the pupil
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
7
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cataract surgery and lens implantation
size is smaller than the intended capsulotomy size despite intense topical application of mydriatics, the surgeon faces a major challenge at the start of the surgery. Furthermore, the immediate effects of lens laser treatment are different from conventional phacoemulsification. A postlaser treatment miosis means a narrow pupil after laser pretreatment, which is due to progressive miosis in a previously proper size pupil after the completion of laser treatment. This can occur in approximately 5–32% of all cases [12,37 ,50,51]. Immediately after femtosecond laser treatment, the aqueous humor shows a significant rise in prostaglandin E2 and total prostaglandin, which can be responsible for the miosis [52 ]. &
&
Laser-induced miosis Preoperative application of topical NSAIDs can prevent intraoperative miosis during phacoemulsification [14]. The incidence of laser-induced miosis can be decreased to 1% with NSAID pretreatment [53]. In a series of patients, the 9.5% incidence of postlaser pupillary constriction was decreased to 1.23% by additional instillation of a drop of 10% phenylephrine immediately after laser treatment [12]. It seems that the longer the elapsed time between laser pretreatment and commencing intraocular surgery, the smaller the pupils become. It is recommended to start lens removal within 15 min after laser pretreatment [54]. In cases of laser-induced miosis, slow injection of intracameral epinephrine after opening of the laser-assisted incisions would be very helpful to enlarge the pupil again.
Small pupil before the application of laser treatment Anterior chamber integrity is necessary for successful laser application. Any penetration for intracameral injections or inserting pupil dilating devices may result in wound leakage and anterior chamber instability owing to an increase in intraocular pressure (IOP) during suction and corneal applanation. Intracameral mydriatics In a series of 40 eyes with small pupils, intracameral injection of epinephrine was sufficient to achieve a pupil larger than 5.5 mm in 7% of the eyes [28 ]. Kankariya et al. [55] reported results of epinephrine 0.025% and lidocaine 0.75% injection through a 0.8-mm corneal paracentesis, followed by introduction of viscoelastic to achieve further pupillary dilatation and maintain anterior chamber stability during subsequent femtosecond laser pretreatment. In both reports, anterior chamber penetration &&
8
www.co-ophthalmology.com
before laser pretreatment was feasible for the management of small pupils. Viscomydriasis Additional injection of OVD can further dilate the pupil in a considerable proportion of patients [28 ]. This can also result in further anterior chamber stabilization during suction and IOP rise [55]. &&
Iris retractor hooks and Malyugin ring Iris retractor hooks have been used successfully to dilate the pupil without interfering with the docking process [37 ]. Malyugin ring has also been used to keep the pupil dilated [28 ,37 ,55–57]. In all reports, ring insertion was through a 1.8–2.75-mm clear corneal incision without any evidence of anterior chamber instability during laser pretreatment. &
&&
&
CONCLUSION Phacoemulsification in the presence of a small pupil continues to be a challenging situation. Innovations in surgical instruments and techniques may improve patient safety and suggest new treatment paradigms. Preoperative assessment and identification of patients with small pupils or at risk for miosis is important to take compensatory measures to keep the complication rate as low as possible and to achieve excellent visual outcomes. Acknowledgements The article has not been presented in a meeting. The authors did not receive any financial support from any public or private source. The authors have no financial or proprietary interest in a product, method, or material described herein. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Hashemi H, Mohammadpour M, Jabbarvand M, et al. Incidence of and risk factors for vitreous loss in resident-performed phacoemulsification surgery. J Cataract Refract Surg 2013; 39:1377–1382. 2. Chen M, Lamattina KC, Patrianakos T, Dwarakanathan S. Complication rate of posterior capsule rupture with vitreous loss during phacoemulsification at a Hawaiian cataract surgical center: a clinical audit. Clin Ophthalmol 2014; 8:375–378. 3. Belovay GW, Varma DK, Ahmed II. Cataract surgery in pseudoexfoliation syndrome. Curr Opin Ophthalmol 2010; 21:25–34. 4. Negi A, Vernon SA. An overview of the eye in diabetes. J R Soc Med 2003; 96:266–272. 5. AltiaylikOzer P, Altiparmak UE, Unlu N, et al. Intraoperative floppy-iris syndrome: comparison of tamsulosin and drugs other than alpha antagonists. Curr Eye Res 2013; 38:480–486.
Volume 26 Number 1 January 2015
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Small pupil and cataract surgery Hashemi et al. 6. Chang DF, Campbell JR, Colin J, et al. Prospective masked comparison of intraoperative floppy iris syndrome severity with tamsulosin versus alfuzosin. Ophthalmology 2014; 121:829–834. 7. Gogaki E, Tsolaki F, Tiganita S, et al. Iridoschisis: case report and review of the literature. Clin Ophthalmol 2011; 5:381–384. 8. Chang DF. Use of malyugin pupil expansion device for intraoperative floppyiris syndrome: results in 30 consecutive cases. J Cataract Refract Surg 2008; 34:835–841. 9. Storr-Paulsen A, Jørgensen JS, Norregaard JC, Thulesen J. Corneal endothelial cell changes after cataract surgery in patients on systemic sympathetic a-1a antagonist medication (tamsulosin). Acta Ophthalmol 2014; 92:359– 363. 10. Grob SR, Gonzalez-Gonzalez LA, Daly MK. Management of mydriasis and && pain in cataract and intraocular lens surgery: review of current medications and future directions. Clin Ophthalmol 2014; 8:1281–1289. This article is a review on the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control during cataract surgery. 11. Suwan-Apichon O, Ratanapakorn T, Panjaphongse R, et al. 2.5% and 10% phenylephrine for mydriasis in diabetic patients with darkly pigmented irides. J Med Assoc Thai 2010; 93:467–473. 12. Roberts TV, Lawless M, Bali SJ, et al. Surgical outcomes and safety of femtosecond laser cataract surgery: a prospective study of 1500 consecutive cases. Ophthalmology 2013; 120:227–233. 13. Kauffmann S, Commun F, Schoeffler P, et al. Cardiovascular adverse effects due to phenylephrine eye drops in ophthalmic surgery. Ann Fr Anesth Reanim 2013; 32:112–114. 14. Joshi RS. Preoperative use of the topical steroidal and nonsteroidal antiinflammatory agents to maintain intra-operative mydriasis during cataract surgery. Indian J Ophthalmol 2013; 61:246–247. 15. Torro´n C, Calvo P, Ruiz-Moreno O, et al. Use of a new ocular insert versus conventional mydriasis in cataract surgery. Biomed Res Int 2013; 2013:849349. 16. Weddle C, Thomas N, Dienemann J. Improved pupil dilation with medicationsoaked pledget sponges. AORN J 2013; 98:131–143. 17. Hargitai J, Vezendi L, Vigstrup J, et al. Comparing the efficacy of mydriatic cocktail-soaked sponge and conventional pupil dilation in patients using tamsulosin: a randomized controlled trial. BMC Ophthalmol 2013; 13:83. 18. Gupta SK, Kumar A, Agarwal S, et al. Phacoemulsification without preoperative topical mydriatics: induction and sustainability of mydriasis with intracameral mydriatic solution. Indian J Ophthalmol 2014; 62:333–336. 19. Lundqvist O, Koskela T, Behndig A. A paired comparison of intracameral & mydriatics in refractive lens exchange surgery. Acta Ophthalmol 2014; 92:482–485. A randomized study to compare the efficacy and intraoperative safety of intracameral and topical mydriatics. 20. Williams GS, Radwan M, Kadare S, et al. The short to medium-term risks of intracameral phenylephrine. Middle East Afr J Ophthalmol 2012; 19:357– 360. 21. Ba¨ckstro¨m G, Lundberg B, Behndig A. Intracameral acetylcholine effectively contracts pupils after dilatation with intracameral mydriatics. Acta Ophthalmol 2013; 91:123–126. 22. Lundberg B, Behndig A. Intracameral mydriatics in phacoemulsification cataract surgery: a 6-year follow-up. Acta Ophthalmol 2013; 91:243–246. 23. Myers WG, Shugar JK. Optimizing the intracameral dilation regimen for cataract surgery: prospective randomized comparison of 2 solutions. J Cataract Refract Surg 2009; 35:273–276. 24. Ezra DG, Nambiar A, Allan BD. Supplementary intracameral lidocaine for phacoemulsification under topical anesthesia. A meta-analysis of randomized controlled trials. Ophthalmology 2008; 115:455–487. 25. Nikeghbali A, Falavarjani KG, Kheirkhah A. Pupil dilation with intracameral lidocaine during phacoemulsification: benefits for the patient and surgeon. Indian J Ophthalmol 2008; 56:63–64. 26. Lundberg B, Behndig A. Separate and additive mydriatic effects of lidocaine hydrochloride, phenylephrine, and cyclopentolate after intracameral injection. J Cataract Refract Surg 2008; 34:280–283. 27. Lockington D, Macdonald EC, Young D, et al. Presence of free radicals in intracameral agents commonly used during cataract surgery. Br J Ophthalmol 2010; 94:1674–1677. 28. Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Femtosecond laser&& assisted cataract surgery in eyes with a small pupil. J Cataract Refract Surg 2013; 39:1314–1320. A step-by-step approach to the management of small pupil in the setting of laserassisted cataract surgery. 29. Mohammadpour M, Erfanian R, Karim N. Capsulorhexis: pearls and pitfalls. Saudi J Ophthalmol 2012; 26:33–40. 30. Chang DF. Why learn chopping? In: Chang DF, editor. Phaco chop and advanced phaco techniques. New Jersey: Slack Inc; 2013. pp. 3–11. 31. Akman A, Yilmaz G, Oto S, et al. Comparison of various pupil dilatation methods for phacoemulsification in eyes with a small pupil secondary to pseudoexfoliation. Ophthalmology 2004; 111:1693–1698.
32. Fine IH, Packer M, Hoffman RS. Phacoemulsification in the presence of a small pupil. In: Steinert RF, editor. Cataract surgery. Saunders: Elsevier Inc; 2010. pp. 245–258. 33. Kopsachilis N, Carifi G. Phacoemulsification using 8 flexible iris hooks in a patient with a short eye, small pupil, and phacodonesis. J Cataract Refract Surg 2014; 40:1408–1411. 34. Goldman JM, Karp CL. Adjunct devices for managing challenging cases in cataract surgery: pupil expansion and stabilization of the capsular bag. Curr Opin Ophthalmol 2007; 18:44–51. 35. Wilczynski M, Wierzchowski T, Synder A, Omulecki W. Results of phacoe& mulsification with Malyugin ring in comparison with manual iris stretching with hooks in eyes with narrow pupil. Eur J Ophthalmol 2013; 23:196–201. This article compares the results of a new pupil expansion device, Malyugin ring, with manual pupillary stretching with hooks. 36. Wilczynski M, Kucharczyk M. Phacoemulsification with Malyugin ring in an eye with iridoschisis, narrow pupil, anterior and posterior synechiae: case report. Eur J Ophthalmol 2013; 23:909–912. 37. Dick HB, Schultz T. Laser-assisted cataract surgery in small pupils using & mechanical dilation devices. J Refract Surg 2013; 29:858–862. Use of a new pupil expansion device for the management of small pupil in laserassisted cataract surgery. 38. Bell CM, Hatch WV, Fischer HD, et al. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA 2009; 301:1991–1996. 39. Haridas A, Syrimi M, Al-Ahmar B, et al. Intraoperative floppy iris syndrome (IFIS) in patients receiving tamsulosin or doxazosin-a UK-based comparison of incidence and complication rates. Graefes Arch Clin Exp Ophthalmol 2013; 251:1541–1545. 40. Tufan HA, Gencer B, Kara S, et al. Alterations in iris structure and pupil size related to alpha-1 adrenergic receptor antagonists use: implications for floppy iris syndrome. J Ocul Pharmacol Ther 2013; 29:410–413. 41. Shtein RM, Hussain MT, Cooney TM, et al. Effect of tamsulosin on iris vasculature and morphology. J Cataract Refract Surg 2014; 40:793–798. 42. Masket S, Belani S. Combined preoperative topical atropine sulfate 1% and intracameral nonpreserved epinephrine hydrochloride 1:4000 [corrected] for management of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2007; 33:580–582. 43. Perez-Silguero D, Ramallo-Farina Y, Perez-Silguero MA, et al. Comparison of the effectiveness of two different pharmacologic approaches to prevent intraoperative floppy iris syndrome. Arch Soc Esp Oftalmol 2009; 84:549–556. 44. Carifi G, Kopsachilis N. Alpha-1 adrenergic agonists for the prevention of floppy iris syndrome. Ophthalmology 2013; 120:e43. 45. Lorente R, de Rojas V, Va´zquez de Parga P, et al. Intracameral phenylephrine 1.5% for prophylaxis against intraoperative floppy iris syndrome: prospective, randomized fellow eye study. Ophthalmology 2012; 119:2053–2058. 46. Martı´n-Moro JG, Negrete FM, Escobar IL, Miguel YF. Intraoperative floppy-iris && syndrome. Arch Soc Esp Oftalmol 2013; 88:64–76. A comprehensive review on IFIS. 47. Lockington D, Gavin MP. Intraoperative floppy-iris syndrome: role of the bimanual approach. J Cataract Refract Surg 2009; 35:964. 48. Jhanji V, Sharma N, Vajpayee RB. Management of intraoperative miosis during pediatric cataract surgery using Healon 5. Middle East Afr J Ophthalmol 2011; 18:55–57. 49. Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (flomax). Ophthalmology 2007; 114:957–964. 50. Bali SJ, Hodge C, Lawless M, et al. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012; 119:891–899. 51. Nagy ZZ, Takacs AI, Filkorn T, et al. Complications of femtosecond laserassisted cataract surgery. J Cataract Refract Surg 2014; 40:20–28. 52. Schultz T, Joachim SC, Kuehn M, Dick HB. Changes in prostaglandin levels in & patients undergoing femtosecond laser-assisted cataract surgery. J Refract Surg 2013; 29:742–747. This study investigates the intraocular prostaglandin concentrations after femtosecond laser treatment and the potential relationship to miosis. 53. Dick HB, Gerste RD, Schultz T. Laser cataract surgery: curse of the small pupil. J Refract Surg 2013; 29:662. 54. Passut J. Panelists answer questions from femto for cataract webinar. Webinar presented at: ASCRS Eyeworld; September 2011. http://www.eye world.org/article.php?sid=6036&strict=0&morphologic=0&query. 55. Kankariya VP, Diakonis VF, Yoo SH, et al. Management of small pupils in femtosecond-assisted cataract surgery pretreatment. Ophthalmology 2013; 120:2359–2360. 56. Kra´nitz K, Taka´cs AI, Gyenes A, et al. Femtosecond laser-assisted cataract surgery in management of phacomorphic glaucoma. J Refract Surg 2013; 29:645–648. 57. Roberts TV, Lawless M, Hodge C. Laser-assisted cataract surgery following insertion of a pupil expander for management of complex cataract and small irregular pupil. J Cataract Refract Surg 2013; 39:1921–1924.
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
9
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
