EyeWorld Asia-Pacific September 2019 Issue

36 EWAP SEPTEMBER 2019 CATARACT by Maxine Lipner EyeWorld Senior Contributing Writer Saving time with Omidria in FLACS cases A dding Omidria (phenylephrine/ ketorolac, Omeros) to the irrigating solution during femtosecond laser-assisted cataract surgery (FLACS) can not only reduce the need for pupil expansion devices but can also lower surgical time, according to new study results 1 . Investigators found that mean surgical time Ü>à È}˜ˆwV>˜ÌÞ Ài`ÕVi` ˆ˜ cases using Omidria, 8.1 minutes compared with 9.4 minutes for those receiving epinephrine, reported Keith Walter, MD. Often in femtosecond cases when the laser makes the capsulotomy within a few minutes, the pupil will decrease, VÀi>̈˜} `ˆvwVՏÌÞ° ivœÀi Omidria, the solutions were either to use a Malyugin ring to push it back open or hooks to keep it expanded. With the Malyugin ring, there’s concern that the pressure could cause a radial tear, and with hooks, an open capsule can be troubling because you don’t want to catch the edge of it, Dr. Walter said. Less mechanical intervention In the study, investigators examined 100 cases in which Omidria was used in the irrigating solution and a previous 100 consecutive eyes in which only epinephrine was used in the bottle, Dr. Walter said. All cataracts were removed by the same surgeon, with the same laser, and each patient received This article originally appeared in the May 2019 issue of EyeWorld . It has been UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ permission from the ASCRS Ophthalmic Services Corp. Contact information Walter: kwalter@wakehealth.edu P ost-laser miosis is a commonly encountered (10–30% incidence) and unwanted side effect of femtosecond laser-assisted cataract surgery (FLACS). Prostaglandin release following laser anterior capsulotomy and lens fragmentation presumably induces miosis after laser application. Risk factors may include age, proximity of laser anterior capsulotomy treatment zone to the pupillary edge, duration and extent of laser treatment. Despite aggressive use of preoperative topical mydriatics/cycloplegics and NSAIDs, post-laser miosis may still occur and the resulting suboptimal pupil size may lead to untoward intraoperative complications such as iris trauma, capsular damage, >˜` «œÃ̜«iÀ>̈Ûi ˆ˜y>““>̈œ˜° Thankfully, there are a variety of effective tools for counteracting post-laser miosis. Administration of intracameral epinephrine is generally successful in reversing most of laser-induced miosis and allowing uninterrupted, uneventful nuclear disassembly and IOL implantation. Reapplicaton of dilating regimen using topical phenlyephrine 10%, tropicamide and NSAID or similar combinations ˆ˜ LiÌÜii˜ ̅i >ÃiÀ «ÀœVi`ÕÀi >˜` «…>Vœi“ՏÈwV>̈œ˜ “>Þ ÀiÃ̜Ài adequate pupil dilation. A variety of pupil expansion devices (PED) “>Þ >Ãœ Li i“«œÞi` >Ì Ì…i ̈“i œv «…>Vœi“ՏÈwV>̈œ˜ ̅œÕ}… there is some concern about damaging the anterior capsule during PED application. Walter and coworkers compared the surgical times of eyes undergoing FLACS with phenylephrine 1.0%-ketorolac 0.3% (Omridia, Omeros) versus epinephrine 1 μm/ml incorporated into the ˆÀÀˆ}>̈œ˜ ܏Ṏœ˜° /…iÞ œLÃiÀÛi` > È}˜ˆwV>˜Ì Ài`ÕV̈œ˜ œv œ«iÀ>̈Ûi duration from 9.0 to 8.1 minutes when phenylephrine-ketorolac infused irrigation solution was used and a reduction in need for PED application. In markets where the formulation is available, this is a simple, easily employable maneuver which may facilitate lens removal and prevent small-pupil surgery complications. There seems to be no È}˜ˆwV>˜Ì i>À˜ˆ˜} VÕÀÛi ˜œÀ Ã>viÌÞ Vœ˜ViÀ˜Ã vœÀ Ṏˆâˆ˜} ̅ˆÃ Ó> pupil remedy. The main limitation of Omridia utilization lies in cost effectiveness. /…i ܅œiÃ>i VœÃÌ œv "“Àˆ`ˆ> ˆÃ 1-f{ÈxÉ՘ˆÌ] ܅ˆV…È}˜ˆwV>˜ÌÞ >``à ̜ «ÀœVi`ÕÀ> VœÃÌð 7…i̅iÀ ̅i ̈“i Ã>ۈ˜}à œv £ “ˆ˜ÕÌi ˆÃ ÕÃ̈wi` by this added cost is subject to economic analysis. If used routinely, the added costs place additional burden on payors. A practical approach may be to initially administer intracameral epinephrine >˜` «ÀœVii` ̜ "“Àˆ`ˆ> ÕÃi ˆv `ˆ>̈œ˜ ˆÃ ˜œÌ ÃÕvwVˆi˜Ì œÀ ÃÕÃÌ>ˆ˜i`Æ however, when used on a case-by-case basis, the additional time to prepare the ophthalmic irrigating solution may negate gains from shortening surgical times. Overall, Omridia is a welcome though costly tool for facilitating post-laser miosis among eyes undergoing FLACS. Editors’ note: Dr. Uy is a consultant for Alcon and LENSAR. Harvey Uy, MD Medical Director, Peregrine Eye and Laser Institute, Makati City, Philippines harveyuy@yahoo.com ASIA-PACIFIC PERSPECTIVES