EyeWorld Asia-Pacific June 2020 Issue

CATARACT EWAP JUNE 2020 27 A dequate pupillary dilation is essential for successful cataract extraction. Poor dilation can lead to a multitude of surgical complications including capsular rupture, iris trauma, endothelial damage, and overall poor visual outcomes. Topical pharmacologic pupillary dilation has been the traditional standard of care, however, disadvantages include unpredictable dilation, long induction time, corneal toxicity, and systemic absorption. The advent of pupillary expansion devices (PED) has provided an additional tool to improve pupillary dilation; however, their use is associated with increased operative time, increased cost, and iris injury. Recently, intracameral mydriatics have gained popularity due to their rapid onset, longer maintenance of dilation, reduced incidence œv ˆ˜ÌÀ>œ«iÀ>̈Ûi yœ««Þ ˆÀˆÃ syndrome, and reduced use of PED. Although intracameral mydriatics have been widely adopted, their utility in resident trainee surgery has not been studied. This article examines the use of PED, operative times, and surgical costs with traditional topical mydriatics versus intracameral mydriatics during resident- performed cataract extraction at a Veterans Affairs hospital. Summary In this retrospective study, resident-performed cataract surgeries at the Iowa City Veterans Affairs Hospital performed in two different time periods (June 2017 to December 2017 and June 2018 to December 2018) were reviewed for differences in PED use, operating times, and surgical costs when using traditional topical dilation (tropicamide 1%, cyclopentolate £¯] >˜` «…i˜Þi«…Àˆ˜i Ó°x¯ ܈̅ä°x “ œv «ÀiÃiÀÛ>̈Ûi‡ free 1% lidocaine given intracamerally at the start of surgery and 1:1000 epinephrine ܈̅ˆ˜ ˆÀÀˆ}>̈œ˜ yՈ`® ÛiÀÃÕà intracameral mydriasis (topical tropicamide 1%, preservative- free lidocaine 1% mixed 9:1 with £\£äää LˆÃՏwÌi‡vÀii i«ˆ˜i«…Àˆ˜i given at the beginning of the case without any additional epinephrine in the irrigating yՈ`®° /…i Ìܜ ÃÌÕ`Þ «iÀˆœ`à were selected based on a change in perioperative pupil dilation protocol from topical dilation to intracameral dilation. Each study period included two and a half resident rotations over the same 6-month period a year apart. Cases were included if the resident surgeon was the primary cataract surgeon ܈̅œÕÌ Ãˆ}˜ˆwV>˜Ì ˆ˜ÌiÀÛi˜Ìˆœ˜ by the attending surgeon, and the dilation protocol adhered to the mydriatic protocol. This information was derived from procedure reports. Age, gender, history of tamsulosin use, PED use during surgery, case surgical times, and the surgical costs for dilation and PED use were compared for the two study groups. Fisher’s exact two-tailed test was used to compare the use of PED between the two groups. Paired t-tests were used to test for differences in surgical times between the two study groups. Each study group included 267 cases and were remarkably similar in the reported patient characteristics: average «>̈i˜Ì >}i œv ÇÓ°x Þi>Àà œ`] 97% males, and 28% use of tamsulosin in 2017 versus 29% in 2018 among the study patients. For the topical mydriasis group, 31.1% of cases required PED ÕÃi° œ˜ÛiÀÃiÞ] œ˜Þ £Î°x¯ œv intracameral mydriasis cases required PED use. For those patients on tamsulosin, PED ÕÃi Ü>à xӰǯ ˆ˜ ̅i ̜«ˆV> group compared to 17.9% in the intracameral group. The use of PEDs added, on average, 7.1 minutes to the surgical time compared to cases without PED use. Intracameral use did not change surgical times among PGY3 surgeons but did result in a small decrease in surgical times among PGY4 cases. In comparing surgical cost, the total cost for the use of topical mydriatics was US$13,990 in study group 1 1-fxÓ°{ä vœÀ ÌÀœ«ˆV>“ˆ`i] phenylephrine, cyclopentolate) Vœ“«>Ài` ̜ 1-fxÓÎ ˆ˜ study group 2 (solely topical tropicamide). The total cost Review of “Pupil expansion device use and operative outcomes with topical dilation versus intracameral epinephrine in resident-performed cataract surgery” by Cherie Fathy, MD, Ollya Fromal, MD, Samir Patel, MD, Travis Peck, MD, Marisa Schoen, MD, Meera Sivalingam, MD Contact information Uhler: Tara.Uhler@jefferson.edu This article originally appeared in the April 2020 issue of EyeWorld . It has been UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ permission from the ASCRS Ophthalmic Services Corp. Tara Uhler, MD Director of the ophthalmology residency program Wills Eye Hospital Philadelphia, Pennsylvania