Archive January 2019 XX, No. 1

Call in the Big Guns to Deal With Small Pupils

These drugs and devices promise to take the challenge out of the challenging cataract cases.

Daniel Cook

Daniel Cook, Executive Editor


Jeffrey Whitman, MD
OPENING UP Most surgeons routinely use a topical or intracameral medication to keep pupils dilated throughout surgery.

Small pupils are a sizable concern for your cataract surgeons. They increase the risk of serious complications, including damage to the iris, capsular tears, vitreous loss, and retained lens fragments and cortical material. It’s estimated that about 10% of cataract patients are at risk of intraoperative miosis, so chances are your surgeons will have to deal with the issue at least once during a busy day of surgery. Thankfully, there are several drugs and devices that will dilate pupils wide enough to give physicians the views they need to perform safe and effective surgery. Here’s a rundown.

Mydriatic agents

Pharmaceutical options for maintaining pupil dilation do not involve the mechanical manipulation of the iris, so there’s less risk of cystoid macular edema developing after surgery, says Rex Hamilton, MD, MS, FACS, a cataract and refractive surgeon at Santa Monica (Calif.) Eye Medical Group. Dr. Hamilton says most surgeons routinely use topical or intracameral agents to create intraoperative mydriasis, but differ in their drugs of choice. He typically injects Shugarcaine (a lidocaine-epinephrine compound) to keep pupils dilated.

Lidocaine provides anesthetic comfort and also paralyzes the pupil’s sphincter muscle, causing the pupil to open wide, says Kevin Miller, MD, chief of the cataract and refractive surgery division at the David Geffen School of Medicine at UCLA. Shugarcaine stimulates the pupil’s dilator muscle, which also helps to maintain pupil dilation, he adds.

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