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Archive February 2018 XIX, No. 2

You Can't Put a Price on Pupillary Dilation

Don't hesitate to invest in the drugs and devices that make cataract surgery safer and more efficient.

Daniel Cook

Daniel Cook, Editor-in-Chief


Eye Dilation
EYE OPENING Jeffrey Whitman, MD, injects a compounded mixture of phenylephrine and lidocaine into the anterior chamber to maintain mydriasis.

Working through small pupils during cataract surgery must be as frustrating as trying to squeeze a profit out of what Medicare pays your facility to host the case. Reimbursements certainly aren't going to increase anytime soon and inadequate intraoperative mydriasis is becoming an increasingly common problem, so team up with your surgeons to find a cost-effective way to dilate pupils and dial up revenues.

A growing number of cataract patients are showing up with small pupils in part because more male patients are using prostate medications, which affect the iris dilator muscle. Intraoperative floppy iris syndrome (IFIS) occurs in at least 75% of men on those medications and in as much as 25% of the general patient population, says Steven Silverstein, MD, FASC, an ophthalmic surgeon in Kansas City, Mo. Plus, there are plenty of patients whose pupils don't dilate fully or don't dilate to the extent that they did during pre-op clinic visits.

Maintaining pupillary dilation improves access to the eye and visualization of delicate anatomy, factors that decrease risk of posterior capsular tears, zonular damage and vitreous loss, and make cataract removal easier and safer. It also lets surgeons perform complex cases more efficiently. Surgeons have plenty of available options to keep pupils dilated during surgery, from hooks and rings to pharmaceutical agents. The optimal choice for your facility demands striking a balance between cost and clinical efficacy.

  • Iris hooks. Reusable iris hooks don't add to case costs, but the initial capital expenditure will run your facility a couple hundred dollars. A small stab incision is made in the limbus, through which surgeons insert 4 hooks to maintain pupil dilation. In patients with IFIS, the iris tends to prolapse out of the wound, which can be prevented by placing the hooks in a diamond configuration underneath the main temporal incision, says ophthalmic surgeon Nick Mamalis, MD, co-director of the Intermountain Ocular Research Center in Salt Lake City, Utah.
  • Iris rings. Single-use rings cost approximately $125 and reusable options run approximately $50 per use. Surgeons insert ring-type devices through a clear corneal incision to create and maintain pupil dilation. There are several models available that are largely effective in giving surgeons the space they need to operate. Surgeons must decide which design and delivery method — a circular or square dilation and inserter or separate injector — works best in their hands. During surgery, surgeons must be aware of the ring's position on the pupil, so they don't dislodge the device when sliding instruments into and out of the eye.
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