EyeWorld Asia-Pacific September 2013 Issue

11 Septemebr 2013 EWAP FEAturE paralyzing the pupil sphincter, and the epinephrine stimulates the pupil dilator,” Dr. Culbertson said. One recent approach is to inject phenylephrine 1.5%. This is something that must be compounded in the United States, Dr. Culbertson said. It can be combined with lidocaine. At the Bascom Palmer center, where there is a compounding pharmacy on the premise, this has been dubbed Bascom Palmer-caine. “It seems to be very effective in preventing pupil constriction, and it makes the iris less floppy in IFIS,” Dr. Culbertson said. In traditional small pupil cases, where visualization is inadequate from the start, after topical dilation has been tried, pharmacological methods may not do the trick, said Ramon Lorente, MD , chairman, Department of Ophthalmology, Complexo Hospitalario Universitario Ourense, Spain. “In our experience, pharmacological methods such as intracameral adrenaline or phenylephrine are not effective as they do not increase the previous topical dilation,” Dr. Lorente said. The new ‘book’ on IFIS For IFIS cases, however, it may be a different story. Dr. Lorente and fellow investigator Victoria de Rojas, MD , chairman, Department of Ophthalmology, Complexo Hospitalario Universitario A, Couruna, Spain, together with others, recently considered how prophylactic administration of intracameral phenylephrine (IPH) would affect the development of IFIS. “After prospectively reviewing the efficacy of this approach in a large series of patients at risk of IFIS, starting in 2007, we decided to evaluate the efficacy of IPH 1.5% as prophylaxis against tamsulosin- associated IFIS,” Dr. Lorente said. The study, published in the October 2012 issue of Ophthalmology, also analyzed the ability of the phenylephrine to reverse the floppy iris syndrome. During the study, signs of IFIS were observed in 88.09% of eyes that were randomized to receive balanced salt solution. However, no signs of IFIS were seen in eyes that received 0.6 ml of non-preserved bisulfite-free IPH 1.5%. Significant pupil constriction, iris prolapse, or both occurred in 54.76% of the balanced salt solution eyes, Dr. Lorente reported. “However, the condition was successfully reversed with IPH, with a significant increase in pupil size after IPH administration,” Dr. Lorente said. He was encouraged by the results. “Our study clearly showed that intracameral phenylephrine is a highly efficient measure for prophylaxis against IFIS,” he said. “Moreover, the drug can reverse IFIS, restoring iris rigidity and causing the pupil to return to its preoperative size.” Currently, Dr. Lorente is now dilating patients at risk of IFIS directly with intracameral phenylephrine 1.5% together with lidocaine 2%. This, he finds, avoids the need for topical instillation of dilating drops, with good results. “The dilated pupil size is slightly smaller than that obtained after topical mydriatics, but it lasts longer and it avoids systemic absorption with its possible cardiovascular adverse effects,” he said. Dr. Malyugin usually starts his surgery by injecting intracameral epinephrine or phenylephrine. “This strengthens the iris muscle and increases the rigidity of the iris tissue and also increases the diameter of the pupil,” he said. “After that I judge whether or not posterior synechiae are present because sometimes when I’m able to dissect those I can free the pupil, which becomes wider, and there is no need for any pupil expansion devices.” Femtosecond laser extracurriculars One other new approach is use of the femtosecond laser. In the United States it is strictly off label to use this on patients with small pupils, Dr. Culbertson said. If the pupil is too small the laser won’t be able to soften or fragment the lens since it can’t cut through the iris. However, since the femtosecond is potentially advantageous for many ancillary conditions that may also plague those with small pupils, such as weak zonules, some doctors have begun giving it a try. This has meant first expanding the pupil to make femtosecond use possible. “I know of some doctors who have put in one of the dilating solutions like Shugarcaine, phenylephrine, put in viscoelastic through a small incision, and opened the pupil,” Dr. Culbertson said. They put in a Malyugin ring and swing the patient over to the femtosecond laser [to do] the capsulotomy, lens fragmentation and softening, and other incisions. Then they bring the patient back under the microscope for traditional phacoemulsification, he explained. Dr. Malyugin pointed to work done by Zoltan Nagy, MD , Budapest, who uses the femtosecond laser in tandem with the Malyugin ring. “After injecting the Malyugin ring, he removes viscoelastic from the anterior chamber because this can have some issues with the laser energy hitting the capsule, and then creates the capsulorhexis and nucleus fragmentation (with the femtosecond laser) and proceeds with the cataract procedure,” Dr. Malyugin said. Overall, Dr. Culbertson is encouraged by recent improvements in small pupil cataract techniques. “Fifteen years ago, small pupil cases were problematic,” he said. “Then we learned to stretch the pupil and started using hooks and rings to enlarge the pupil, as well as pharmacologic enlargement. I think that having to perform the operation while the pupil is small is uncommon with the technology and the techniques that have developed over the last 15 years.” EWAP Editors’ note: Dr. Culbertson has financial interests with OptiMedica (Sunnyvale, Calif., USA). Dr. Lorente has no financial interests related to this article. Dr. Malyugin has financial interests with MST. Contact information Culbertson: wculbertson@med.miami.edu Lorente: rlorenteoftal@yahoo.es Malyugin: boris.malyugin@gmail.com