Medications in Pediatric Cataract Surgery
Daniel J. Lattin, MD, MS
PREOPERATIVE DILATING DROPS
The primary goal is to achieve adequate dilation, which can be difficult in some congenital cataract patients. The secondary goal is to limit possible systemic side effects.
Typically, a combination of cyclopentolate 1% or 2%, phenylephrine 2.5% or 5%, and/or tropicamide 0.5% or 1%, depending on the age of the patient.
Younger children (<2-3 years old): Duke Peds mix = Cyclopentolate 1% and phenylephrine 2.5%.
Older children (>2-3 years old): Duke Adult mix = Tropicamide 0.5% and phenylephrine 5%.
If a patient is not dilating after normal drop administration, soak a cotton-tipped applicator or cellulose eye spear with the dilating drop, then place the cotton-tip into the fornix and “rough up” the conjunctiva in the fornix to aid with absorption. Leave the applicator/spearin the fornix until adequate dilation is achieved.
Make sure to warn the anesthesiologist to monitor the blood pressure and heart rate as the phenylephrine can cause the blood pressure to elevate and heart rate to drop quite significantly. If there are significant cardiovascular changes, remove the applicator/spear.
EPINEPHRINE 1:1000 SOLUTION
Add to the irrigating solution (0.5 mL of epinephrine 1:1000 per 500 mL bottle) to aid with intraoperative pupillary dilation.
TRYPAN BLUE
Can be used to help visualize the anterior capsule, especially if performing a manual capsulotomy or in dense or white cataracts (Fig. 3.1).
Trypan can cause the anterior capsule to be more friable and thus may increase the risk of a radial tear, although pediatric capsules tend to be more elastic than adult capsules in general.
FIGURE 3.1. Trypan blue to stain dense white anterior capsule in a 11-year-old girl with count fingers (CF) vision due to traumatic cataract. (Courtesy of Jolene Rudell, MD PhD and Laura Huang, MD.)
Prior to injecting viscoelastic, fill the anterior chamber with trypan blue and wait for ˜30 seconds. Use BSS to wash out the trypan.
Trypan Blue can temporarily stain the corneal endothelium, so some surgeons prefer to place a filtered air bubble into the anterior chamber prior to introduction of the Trypan to minimize this effect.
OPHTHALMIC VISCOELASTIC DEVICES
Types of ophthalmic viscoelastic devices (OVDs) and common uses:
High viscosity (cohesive) OVDs, for example, Provisc, Healon:
Better for creating space (expanding the capsular bag for IOL injection, dissecting adhesions, expanding the pupil, etc.).
Easier to remove at the end of a case.
Can rapidly leave the anterior chamber during surgery.
Superviscous (high molecular weight) OVDs, for example, Healon GV:
Useful for flattening the anterior lens when performing a manual anterior capsulotomy.
Will cause very high postoperative IOPs if left in the anterior chamber.
Low viscosity (dispersive) OVDs, for example, Viscoat, Ocucoat:
Can be used to help protect the corneal endothelium, or to “plug” a defect in the posterior capsule to prevent vitreous loss.
Often combined with a cohesive OVD in a “soft shell” technique.
Use a dispersive OVD to fill the anterior chamber, then inject a cohesive or high molecular weight OVD directly on to the anterior capsular surface.
Useful for performing a manual rhexis to combine the benefits of dispersive and cohesive OVDs.
Harder to remove completely at the end of surgery—take extra care to adequately remove to prevent a postoperative IOP spike.
Effect on IOP:
Both cohesive and dispersive viscoelastics can cause a postoperative IOP spike in the first 24-48 hours after surgery if not removed completely at the end of the case. Consider using acetazolamide to prevent an IOP spike (see below), especially since you may not always get an ideal examination or IOP on postoperative day 1 in children.
If leaving a child aphakic, use of viscoelastic can be minimized; this has the additional benefit of minimizing the risk of a postoperative IOP spike.
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