Publication Exclusive: Does [pupil] size matter? How premium surgeons can avoid the inevitable

Every day when a premium surgeon enters the operating room to perform ophthalmic surgery, pupillary dilation — the portal to the operative field — will inevitably have a major stake in the success and outcome of the surgery. As a cataract surgeon, I am amazed how often intraoperative miosis and/or small pupils at the outset of a case can wreak havoc for even the most experienced anterior segment surgeons.

As we know, intraoperative miosis is frequently unpredictable or may be associated with conditions such as intraoperative floppy iris syndrome associated with systemic use of alpha-1 adrenergic antagonists (all ending with –osin), pseudoexfoliation syndrome, diabetes mellitus, prior history of uveitis, prior history of trauma or intraocular surgery, and most recently femtosecond laser-assisted cataract surgery (FLACS). Pupil size does matter, and a well-known colleague of mine, Johnny L. Gayton, MD, once reminded me that “pi r squared,” or the area of a circle, is probably the geometry lesson I slept through in high school. Intraoperative pupillary diameter, if starting at a 6-mm diameter, is reduced to 3.5 mm during surgery; this reduction represents a 66% reduction in operative viewing field for the surgeon. And most of us know what can happen next — a visit to our cardiologist postoperatively.

Mitchell A. Jackson

There are several pharmacological and surgical approaches to avoid the inevitable small pupil during surgery. When pupils are less than 5 mm from the outset, I still implement my personal preoperative pharmacological recipe of cyclopentolate 1%, two sets placed by patient at home prior to leaving for the surgery center, with repeat cyclopentolate 1%, phenylephrine 2.5%, and Prolensa (bromfenac 0.07%, Valeant Pharmaceuticals) at the surgery center. I then use one of many surgical devices for pupillary expansion, such as the APX spring-like device (APX Ophthalmology Ltd, Israel), Malyugen ring (MicroSurgical Technology), Grieshaber iris retractors (Alcon) or Beehler pupil dilator (Moria). Personally, I find the disposable APX device to give the best pupillary dilation and is the easiest to remove from the eye at the end of the case. I use MST capsular tension hooks to keep pupils larger and stabilize the capsular bag for phacoemulsification when there is brittle pseudoexfoliation and significant phacodonesis seen at the slit lamp preoperatively. Ike K. Ahmed, MD, FRCSC, has a novel technique of using iris retractors to stabilize a zonular compromise and gluing in the back end of the iris retractor into a scleral tunnel no different than the glued IOL technique described by Amar Agarwal, MS, FRCS, FRCOphth. When a pupil is at least 5.25 mm or greater at the start of the procedure, my main goal is to prevent intraoperative progressive miosis as the case proceeds. In FLACS cases, I always place a drop of Paremyd (hydroxyamphetamine hydrobromide 1%/tropicamide 0.25%, Akorn) immediately after the femtosecond portion of the cataract procedure is completed.

Click here to read the full publication exclusive, The Premium Channel, published in Ocular Surgery News U.S. Edition, August 10, 2015.