Hi my name is Denise Johnson, I'm faculty at Kellogg Eye Centre University of Michigan, and today I'm going to be talking to you about small pupil cataract surgery. So the goal of this, lecture is to define what a small pupil is, and how it affects the critical steps in cataract surgery, describe some causes of small pupil, pre-operative medications that can be used, different intra-operative techniques to help expand the pupil, billing considerations, and then what to say to the patient. So we'll start with the pretest. First question. A small pupil can increase the risk of complications during the following steps of cataract surgery. A irrigation and aspiration. B hydrodissection. C phacoemulsification. D capsulorrhexis. E both b and d. And f all of the above. Question two, a small pupil can be caused by the following conditions. A Pseudoexfoliation syndrome. B Pigmentary dispersion syndrome. C surgery. D Chronic mydriatic use. E both A and C, and F all of the above. So a small pupil technically is defined as a pupil less than four millimeters. But really any size pupil where you can't see enough to do the surgery can be considered a small pupil. So a small pupil affects various stages of cataract surgery. The first step it affects would be your capsuresis. We often use the size of the pupil as a guide to constructing the capsulohexis. So if you have a small pupil, the capsulohexis tends to be very small. And this can lead to difficulties in irrigation and aspiration when trying to remove the subincisional cortical material. The other step it can effect would be hydrodissection with a small pupil it may seem the fluid wave are more difficult. Phacoemulsification can also be effective as far as being able to see the nuclear fragments to remove them during the phaco step. During INA, as I indicated earlier, if the pupil's too small it makes removing the sub-cortical material very difficult. And, lastly, inserting the intraocular lens. So there are various causes for a small pupil. The first includes a fibrotic pupillary sphincter. And there are different ideologies that follow under this category. The first would be pseudoexfoliation syndrome, which typically on clinical exam looks like kind of dandruff-like material, which you can see in this photograph here. This kind of whitish. A dandruff fluffy material is the pseudoexfoliation material. Also when the pupil is dilated, you can see a, almost like a target appearance on the lens capsule where the iris tissue rubs against the lens. In glaucoma patients who may be on chronic miotic use the pupil may be scarred. Into a smaller position and then in cases of rubeosis which can occur in any type of condition or under inflammation often times the pupil will not dilate very well. Posterior synechiae is essentially where the iris tissue is adherent to the lens and this occurs in any case where inflammation happens in the eye and so it could be. From trauma from surgery or just from inflammation in itself. Other causes for a small pupil include an older age. In general older people do not dilate as well ectropion uvea, where the pigmented layer of the irish tissue. Has migrated on to the anterior surface of the iris. And as a result the pupil just does not dilate very well. And also in diabetic patients, in general, they do not dilate very well either. The last major category would be alpha one antagonists. And these are medications. A lot times that are used for blood pressure control or patients who have prostate issues. If you review their medication history it's really important to see if any of these medications are on the list. Even if it may not be on the list it's also important to ask them if they've ever been on these medications in the past. Because, for example, with Flomax, even just a brief episode of using that medication in the past can still have a lasting effect on the pupil. Pre-operative medications. First question. The following medications prevent miosis during surgery. A, Flurbiprofen. B, Tamsulosin, c, preservative-free epinephrine, d, moxifloxacin, e, both a and c, and f, all of the above. So the routine dilating medications are going to vary depending on the physician but in general we typically start with a mydriatic such as 2.5% phenylephrine. And a cycoplegic agent such as tropicamide, which comes in both the 0.5% as well as 1%. Other preoperative medications that can be considered include 10% phenylephrine, which you may want to use if the patient doesn't dilate very well, but you want to make sure that their blood pressure is well-controlled, because 10% phenylephrine. Can cause an elevation in blood pressure. Medications such as cyclopentolate or atropine can sometimes be used several days before the patients undergo cataract surgery to see if that can help dilate the pupil. And lastly, flurbiprofen is a non-steroidal anti-inflammatory that can be used to prevent miosis during cataract surgery. We're going to move on to intra-operative pupil expansion techniques. Question number one. The following technique can be employed to increase the size of the pupil during surgery, A. Iris Hooks, B. Mechanical stretch with a Kuglen Hook, C. Malyugin ring, D. Pupil expansion with Provisc, and E. All of the above. So the first mechanism to start with, would be synechialysis. So, this is typically done in cases of posterior synechia. Again, just to review, that's when the iris tissue is adherent to the lens. So there are two different ways that this can be managed. One would be using viscoelastic dissection. So essentially you're taking your viscoelastic cannula and you're finding an area where the iris tissue is not adherent to the lens, and you stick the cannula underneath the iris tissue and then you inject and the viscoelastic helps to pull off the iris tissue from the anterior lens. The other option is a cyclodialysis spatula where, again, you're going in underneath the iris tissue and you are physically removing bad adhesion. Other mechanisms include either using a Collar Button or a Kuglen Hook. And in both of these cases what you're doing is you're stretching the pupil. Again kind of finding an area where the iris tissue is not adherent to the lens. And you mechanically stretch the pupil to break the adhesions. Another way to increase the size of the pupil during surgery is using medications. So the first one would be preservative-free epinephrine, which is typically put in the BSS ball during cataract surgery to help to maintain pupil dilation. The other agent would be viscoelastic, using, like, a higher molecular weight viscoelastic such as ProVisc. This can help to keep the pupil dilated during surgery. Now we're going to move on to pupil stretch. Again, this is typically used in cases where posterior synechiae or in cases of fibrotic pupils. One thing to keep in mind if you do, do pupil stretch in fibrotic pupils, it's not unusual to see some bleeding occur. And again that's just because of the scar tissue that's present on the pupillary sphincter. However you don't want to use pupil stretch in cases of floppy iris because that's just going to make the iris more pronounced and it's going to complicate the surgery even more. Also, you tend not to want to do it in a shallow anterior chamber because there's a risk that the instruments may hit the cornea and cause some endothelial dysfunction. Iris hooks can be used to help dilate the pupil. Again, the indications for Iris Hooks included the shallow anterior chamber or if you know in advance that you possibly need to convert from phaco to extracapsular cataract surgery, Iris Hooks can be very beneficial. However, you don't want to use them in cases of a narrow palpebral fissure because the Iris Hooks themselves can get in the way. And sometimes it's very difficult to place because of a limited space. We have the Malyugin Ring which is very popular nowadays, it comes in both a 6.2 as well as a 7mm size. And essentially it's a ring device that helps to dilate the pupil. And its major indications include floppy iris, and in cases of a narrow palpebral fissure. However, you don't want to use it in cases where you're going to be using other types of intraocular hardware, or in cases where you need to convert to extra cap cataract extraction. Other pupil expansion techniques which tend not to be used as much anymore include removing a portion of the iris tissue. So, the first option would be a Sphincterotomy where essentially you're creating small cuts in the pupilary border to help physically enlarge the pupil. Then the other would be doing a Sector Iridectomy where essentially you take a piece of the iris tissue. And again, this helps to enlarge the size of the pupil. Obviously, ideally, these Techniques are kind of more of a last resort because these will physically affect the appearance of the pupil afterwards. Another question. Which medication is most commonly associate with intraoperative floppy iris syndrome? A, terazosin. B, doxazosin. C, prazosin or D, tamsulosin. Talking briefly about intraoperative floppy iris syndrome, also known as IFIS, is typically associated with tamsulosin, also known as flomax, which is a very common medication which people are put on for prostate issues. This medication is an alpha one antagonist, and it leads to issues with small pupil developing during surgery. Typically it tends to happen during stages of phacoemulsification where you insert the phaco and suddenly the pupil will shrink and the floppy iris will want to go to the wound and come out of the wound as well. So typical management includes the Malyugin ring or the use of epi-Shugarcaine. Epi-Shugarcaine is a combination of epinephrine. Lidocaine and dss so you get a combination of maintaining pupil dilation as well as anesthesia as well. Changing gears going to talk a little bit about billing the small pupil. The routine cataract surgery has a CPT code of 66984. Because small pupil tends to be a little bit more complicated, it's considered as complex cataract extraction and has the CPT code of 66982. To use this code it's really important that you document in your clinic note, as well as in the operative report. That myosis is a diagnosis. You want to make sure that you document the size of the pupil in your clinic note, as well. As some of you may be aware, this year in 2013, there have been some reductions as far as the reimbursement of cataract surgery. And the complex cataract extraction is one of those types of cataract surgery that has seen a reduction in RVUs. Lastly, we want to talk about informing the patients. It's really important that you discuss with the patients the extra steps that's going to be involved when they have a small pupil. So just so they're aware that the surgery might be a little bit longer. It may require the use of extra instruments, but the other issue to keep in mind is that sometimes when you're mechanically stretching the pupil, the pupil may not necessarily look the same after the surgery. So it's really important again that you inform the patient that their pupil may be permanently dilated after the surgery or have an abnormal appearance. Just so they're not surprised about it after the surgery. Other issues to discuss with them is the risk of higher complications with a small pupil. Post tests. Question #1. A small pupil can increase the risk of complications during the following steps of cataract surgery. Number a, capsulorrhexis, b, instillation of intracameral anesthetic, c, phacoemulsification, d, corneal wound construction, e, both a and c, and f, all of the above. So the correct answer in this case would be e, capsulorhexis as well as phacoemulsification. The other stages of cataract surgery where a small pupil will be affected include hydrodissection. As well as inserting the lens. A small pupil can be caused by the following conditions. A. Pseudoexfoliation syndrome. B. Tamsulosin C. Surgery D. Diabetes E. All of the above. And the correct answer is E. All of the above. The following are true regarding the small pupil. A. It is billed as a routine cataract extraction. B. IFIS is commonly associated with the use of Tamsulosin. C. Pupil stretching is a technique that should be used to manage IFIS. D, patients should be informed of the increased risk of complications with a small pupil. E, both B and D, and F all of the above. The correct answer would be E. Answer A is incorrect because as I indicated, small pupil is considered as complex cataract extraction. C is incorrect because if you stretch a pupil in cased of IFIS it's just going to exacerbate the floppiness of the pupil, and it's going to make the surgery more difficult. Thank you.