April 2020


EyeWorld Journal Club
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

Tara Uhler, MD

Director of the
residency program
Wills Eye Hospital
Philadelphia, Pennsylvania

Wills Eye Hospital residents

Intraocular epinephrine is an off-label but inexpensive method for surgical mydriasis. I invited the Wills residents to review this study on the efficacy and cost effectiveness of intracameral epinephrine that appears in the April JCRS issue.

—David F. Chang, MD EyeWorld Journal
Club Editor

Adequate 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 of intraoperative floppy iris 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.


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 1%, and phenylephrine 2.5% with 0.5 mL of preservative-free 1% lidocaine given intracamerally at the start of surgery and 1:1000 epinephrine within irrigation fluid) versus intracameral mydriasis (topical tropicamide 1%, preservative-free lidocaine 1% mixed 9:1 with 1:1000 bisulfite-free epinephrine given at the beginning of the case without any additional epinephrine in the irrigating fluid). The two study periods 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 without significant intervention 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 patient age of 72.5 years old, 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 use. Conversely, only 13.5% of intracameral mydriasis cases required PED use. For those patients on tamsulosin, PED use was 52.7% in the topical 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 $13,990 in study group 1 ($52.40 for tropicamide, phenylephrine, cyclopentolate) compared to $523 in study group 2 (solely topical tropicamide). The total cost for intraoperative epinephrine was $502 for study group 1 (irrigating bottle, $1.26 per case) versus $633 in study group 2 (intracameral, $1.75 per case). In 2017, 74 Malyugin rings ($130/each) and nine iris hooks ($100/set) cost $10,520. In 2018, 33 Malyugin rings and three iris hooks cost $4,590.


While prior studies have shown safety and efficacy of intracameral mydriatics for pupil dilation in cataract surgery,1–4 this is the first study to evaluate the impact of intracameral epinephrine on efficiency and cost of resident-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 findings. Could there have been a change to the surgical curriculum or the surgical instructors that could have improved surgical efficiency 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 times can vary significantly based on level of experience and interest.5 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 floppy iris syndrome6; 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 PED may be influenced by these 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 significant amount of the surgery 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 $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 analysis. Whether the cost savings reported in this study persist if the costs of the physical labor and supplies were included in the analysis and whether similar cost savings can be replicated at other institutions would be interesting to explore in future studies given differences in purchasing power (i.e., different price of medications and devices), operating costs, and regulations (e.g., whether bottles of topical mydriatics could be reused between cases). As the authors note, topical mydriatics cannot be reused across cases in the Veterans Affairs system, and new bottles of these medications were used for each patient. At the authors’ institution, the most expensive topical mydriatic was phenylephrine at $49.50 per case and amounting to a total of $13,216.50 for cases from June through December 2017.
In addition, while this study shows significant cost savings between the two study groups, it would be interesting to see whether there were any significant differences in postoperative complications and outcomes that could impact overall cost per resident case. As the authors noted, there is a risk of dilution errors using intracameral mydriatics made by compounding pharmacies, which can result in corneal endothelium damage. Also, many institutions may not have access to compounding pharmacies onsite; those that have to obtain intracameral mydriatics from outside providers may incur higher costs than those reported in this study.


This retrospective review is the first study to compare the use of intracameral mydriatics to topical dilating drops with regard to surgical cost, PED use, and efficiency during resident-performed cataract surgeries. Although the outcomes of the study may not be applicable to every practice, surgical protocols that include the use of intracameral mydriatics may improve efficiency in the operating room and reduce surgical costs. This study can further be expanded to include a closer examination of postoperative outcomes and complication rates between the two groups, perhaps bolstering their claim of superiority of intracameral mydriatic use.


1. Cionni RJ, et al. Cataract surgery without preoperative eyedrops. J Cataract Refract Surg. 2003;29:2281–2283.
2. Myers WG, Shugar JK. Optimizing the intracameral dilation regimen for cataract surgery: prospective randomized comparison of 2 solutions. J Cataract Refract Surg. 2009;35:273–276.
3. Lundberg B, Behndig A. Intracameral mydriatics in phacoemulsification cataract surgery – a 6-year follow-up. Acta Ophthalmol. 2013;91:243–246.
4. Visco D. Effect of phenylephrine/ketorolac on iris fixation ring use and surgical times in patients at risk of intraoperative miosis. Clin Ophthalmol. 2018;12:301–305.
5. Winter TW, et al. Resident and fellow participation in strabismus surgery: effect of level of training and number of assistants on operative time and cost. Ophthalmology. 2014;121:797–801.
6. Neff KD, et al. Factors associated with intraoperative floppy iris syndrome. Ophthalmology. 2009;116:658–663.

Editors’ note: The authors would like to thank Leslie Hyman, PhD, Bruce Markovitz, MD, Beeran Meghpara, MD, Christopher Rapuano, MD, Zeba Syed, MD, Tara Uhler, MD, and Doug Wisner, MD, for their time and assistance in preparing this manuscript.


: Tara.Uhler@jefferson.edu

Review of “Pupil expansion device use and operative outcomes with topical dilation versus intracameral epinephrine in resident-performed cataract surgery” Review of “Pupil expansion device use and operative outcomes with topical dilation versus intracameral
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