Management of mydriasis and pain in cataract and intraocular lens surgery: review of current medications and future directions

Abstract

Abstract:The maintenance of mydriasis and the control of postoperative pain and inflammation are critical to the safety and success of cataract and intraocular lens replacement surgery. Appropriate mydriasis is usually achieved by topical and/or intracameral administration of anticholinergic agents, sympathomimetic agents, or both, with the most commonly used being cyclopentolate, tropicamide, and phenylephrine. Ocular inflammation is common after cataract surgery. Topical steroids and nonsteroidal anti-inflammatory drugs are widely used because they have been proved effective to control postsurgical inflammation and decrease pain. Topical nonsteroidal anti-inflammatory drugs have also been shown to help maintain dilation. However, use of multiple preoperative drops for pupil dilation, inflammation, and pain control have been shown to be time consuming, resulting in delays to the operating room, and they cause dissatisfaction among perioperative personnel; their use can also be associated with systemic side effects. Therefore, ophthalmologists have been in search of new options to streamline this process. This article will review the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control. In addition, a new combination of ketorolac, an anti-inflammatory agent, and phenylephrine, a mydriatic agent has recently been designed to maintain intraoperative mydriasis and to reduce postoperative pain and irritation from intraocular lens replacement surgery. Two Phase III clinical trials evaluating this combination have demonstrated statistically significant differences when compared to placebo in maintaining intraoperative mydriasis (P0.00001) and in reducing pain in the early postoperative period (P=0.0002). This medication may be of benefit for use in cataract and lens replacement surgery in the near future.

The Relationship between Anterior Chamber Depth, Axial Length and Intraocular Lens Power among Candidates for Cataract Surgery

“…One of the most important indexes to evaluate post cataract surgery emmetropia is intraocular lens (IOL) power (3, 4). Numerous methods and formulas have been suggested for the measurements of IOL power, which are mostly based on axial length (AL), refractive power of the cornea and an estimation of the postoperative distance between the corneal epithelium and the lens.…”

Comparison of the frequency of use of a pupil expansion device with and without an intracameral phenylephrine and ketorolac injection 1%/0.3% at the time of routine cataract surgery

“…An adequately dilated pupil facilitates visualization throughout the surgical procedure. To achieve mydriasis and control of inflammation during cataract surgery, topical and/or intracameral agents have been used to dilate the pupil and to control postoperative pain and inflammation 1. However, topical mydriatics, viscomydriasis, mechanical devices, and off-label intracameral injections have their limitations 10.…”

“…Intraoperative miosis can affect visualization of the surgical field; increase the risk of complications, inflammation, and postoperative pain; and reduce patient satisfaction 1. Failure to maintain an adequate pupil diameter can increase the difficulty of the procedure and increase the risk of intraoperative and postoperative complications 2.…”

“…Maintenance of mydriasis throughout surgery to allow for better visualization of the surgical field and a greater working area within the pupil is crucial for successful surgical outcomes 4. Postoperative pain is associated with clinical outcomes and patient well-being, preventing or reducing postoperative pain can improve patient satisfaction 1,2. Reduction of postoperative pain is important because patient expectations are high in modern cataract surgery and ocular pain, and discomfort represents a common cause of patient dissatisfaction 5…”

“…Intracameral mydriatics increase pupil dilation without causing measurable ocular side effects or influencing the phacoemulsification process negatively 1. They may also improve operating conditions in complicated cataract surgeries, including those with IFIS, by stabilizing the iris during surgery 1.…”