EyeWorld Asia-Pacific June 2020 Issue

CATARACT 28 EWAP JUNE 2020 for intraoperative epinephrine Ü>à 1-fxäÓ vœÀ ÃÌÕ`Þ }ÀœÕ« 1 (irrigating bottle, US$1.26 per case) versus US$633 in study group 2 (intracameral, 1-f£°Çx «iÀ V>Ãi®° ˜ Óä£Ç] Ç{ Malyugin rings (US$130/each) and nine iris hooks (US$100/ ÃiÌ® VœÃÌ 1-f£ä]xÓä° ˜ Óä£n] 33 Malyugin rings and three iris …œœŽÃ VœÃÌ 1-f{]x™ä° Discussion While prior studies have Ŝܘ Ã>viÌÞ >˜` ivwV>VÞ of intracameral mydriatics for pupil dilation in cataract surgery, 1–4 ̅ˆÃ ˆÃ ̅i wÀÃÌ ÃÌÕ`Þ to evaluate the impact of intracameral epinephrine on ivwVˆi˜VÞ >˜` VœÃÌ œv ÀiÈ`i˜Ì‡ performed cataract surgery. This was a retrospective study that compared the use of topical dilation drops versus intracameral epinephrine on PED use, surgical costs, and surgical times in resident- performed cataract surgery. The authors found a reduction in the use of PED, intraoperative costs, and operative times with the use of intracameral epinephrine compared to topical dilation alone. As the authors noted, a limitation is the retrospective nature of this study. Cases were included from two time periods: June 2017 to December 2017 and June 2018 to December 2018. This time period was selected based on a change in the pupil dilation protocol at their institution that resulted in a transition to intracameral epinephrine use with topical tropicamide from traditional topical dilation with three agents (tropicamide, cyclopentolate, and phenylephrine). Additional information on possible confounders that could impact the primary outcomes would be valuable in interpreting the w˜`ˆ˜}ð œÕ` ̅iÀi…>Ûi been a change to the surgical curriculum or the surgical instructors that could have ˆ“«ÀœÛi` ÃÕÀ}ˆV> ivwVˆi˜VÞ between the two study time periods? How much training and prior cataract surgery experience did each resident have prior to the cases included in this study? In addition, it is unclear whether cases included in the study are evenly distributed among the residents in each level and across time periods. As noted by Winter et al. in their analysis of resident and fellow participation in strabismus surgery, operative ̈“ià V>˜ Û>ÀÞ Ãˆ}˜ˆwV>˜ÌÞ based on level of experience and interest. x Future studies performed in a prospective and randomized manner could help eliminate some of these potential confounders. It would also be useful to have additional information on factors that could impact intraoperative miosis. The authors include data on tamsulosin use, which is associated with intraoperative yœ««Þ ˆÀˆÃ Ãޘ`Àœ“i 6 ; however, additional factors such as prior history of uveitis, history of pseudoexfoliation, and the type of viscoelastic used could impact the primary outcomes. The decision of whether to use * “>Þ Li ˆ˜yÕi˜Vi` LÞ Ì…iÃi patient factors, as well as by staff ophthalmologist preference. There may be variability in preference and/or threshold to using PED in resident cases between staff ophthalmologists that could affect outcomes of this study. Furthermore, retrobulbar anesthesia may affect pupillary dilation, and selective cases were included in this study that had undergone a block prior to cataract surgery. Finally, as cases where the staff ophthalmologist performed a È}˜ˆwV>˜Ì >“œÕ˜Ì œv ̅i ÃÕÀ}iÀÞ were excluded from analysis, it would be interesting to know how many of these cases were excluded in each time period. Table 2 in the study details the cost comparison between the two groups, showing cost per case for each of the mydriatics and surgical devices. Analysis reveals almost US$20,000 in cost savings with use of intracameral epinephrine with lidocaine versus topical dilation only at their institution. The authors note that the cost of pharmacy personnel and equipment required to prepare the intracameral epinephrine were not included in the cost Wills Eye Hospital residents.