Combining Viscoelastic with Intracameral Use of Epinephrine
Using this method for cataract surgery provides a more efficient pupil dilation.
BY DOUGLAS A. KATSEV, M.D.

For some time, I have used a family of viscoelastics to perform various aspects of my anterior segment surgeries. I select a dispersive OVD for capsular tears and penetrating keratoplasty and save the viscoadaptive OVD for assisting with the more difficult cases like patients on tamsulosin hydrochloride (Flomax, Boehringer Ingelheim) or a delicate cornea of a Fuch's patient. I also use the viscoadaptive OVD for cases requiring ocular gymnastics where I need optimal control of the anterior chamber. These two types of OVDs work well in many specialty cases; however, I have found for the average case they may be more than the standard surgeon needs.

A more cohesive and higher viscosity OVD, HealonGV (Advanced Medical Optics [AMO], Santa Ana, Calif.) has become a standard for my cataract procedures.

I have always used dilating drops before surgery with multiple applications. The patient initiates the regimen at home and continues drops when they reach the ASC. This method has provided excellent dilation throughout surgery.

Six months ago, I discontinued my dilation procedures before surgery and switched to intracameral epinephrine with HealonGV. I was searching for a more efficient and effective manner to dilate the pupils that eliminated patient burden and minimized preoperative preparations.

Using HealonGV and intracameral epinephrine together is also easier on my staff, as it helps provide excellent dilation in the operating room (OR). With this technique, I have found this cohesive OVD helps push the pupil open, is easy to use and quick to remove.

Technique

I prepare my lidocaine/epinephrine intracameral mix by drawing up 0.2 mL epinephrine and 10 mL of balanced salt solution in separate syringes. After that, I inject the epinephrine into the balanced salt

A patient's eyes 2 hours after having cataract surgery in the left eye:

HealonGV, I will use Healon5 (AMO). This method has eliminated the need for pupil stretching and dilating tools.

The consistency of the results is encouraging. I have performed 450 consecutive cases without vitreous loss and have not had to use pupil expanders on a single patient.

Advantages

There are many benefits of intracameral use of dilation. First of all, it precludes the need for patients to administer dilating drops, which is a cost savings on both ends. Additionally, patients are pleased as they find it more convenient they do not need to be dilated before they come to the OR. This method has been great for the nurses because they can prep the patient for surgery without having to worry about drops. Pupils dilate in less than 20 seconds, so the dilation does not slow my surgery. Postop, patients benefit because pupils return to normal function sooner.

A study showed with intracameral mydriatics that mydriasis reached 95% with a standard deviation of ±3% of its final value within 20 seconds. Within the study, a separate topical mydriatic group was evaluated, and pupils tended to contract less during surgery. The difference between the two groups was significant (P =.0020).1

Things To Consider

This method is not recommended for a resident or beginning surgeon until they are comfortable with their surgical technique. Although I found it works well, a beginning surgeon does not need the added stress of another small part of the operation that could be done before they get started.

For most surgeons, it appears to be helpful to avoid the use of dispersive viscoelastics in difficult cases. The more cohesive viscoelastics help with pupil movement. Therefore, I recommend using Healon or HealonGV. Healon5 is used for such special cases that do not dilate as well. An NSAID is important in maintaining dilation for all cataract procedures no matter which dilation technique is used. Finally, I have found with intracameral epinephrine, dilated pupils tend not to constrict with surgery, but 2 hours later, they become much more constricted than if I had used dilating drops. OM