There are several relatively inexpensive adjuncts that enhance the outcomes of our cataract surgery, especially in complex cases, and more are coming. I will mention those in use in my practice and make a few comments on each.
I still dilate with topical drops, but some surgeons utilize a pledget wettened with phenylephrine, cyclopentolate or tropicamide and a topical anesthetic. I have for decades
added methylparaben-free epinephrine 0.5 mL to the balanced salt solution bottle and while pass-through is available have utilized Omidria (Omeros), a combination of phenylephrine and ketorolac, to enhance and maintain pupillary dilation. Patient comfort during surgery is also enhanced by Omidria.
In most of my patients an IV is started and a small dose of midazolam and fentanyl given by the anesthetist, but in select cases I have used the MKO Melt (midazolam, ketamine and ondansetron, Imprimis) sublingual without an IV with good success. I routinely inject 0.2 mL to 0.3 mL of lidocaine and dilute preservative-free epinephrine (5:1) into the eye after paracentesis. I find this enhances and maintains dilation and increases comfort.
I like to coat the ocular surface with a dispersive ophthalmic viscosurgical device (OVD) or sterile Goniosol (hydroxypropyl methylcellulose), enhancing the surgeon view, protecting the ocular surface and eliminating the need for the assistant to wet the cornea. We nearly all use an OVD in the eye to protect cells, maintain space and, when needed, induce viscodilation. For small pupils and intraoperative floppy iris syndrome, a supracapsular phacoemulsification approach works well for me, dilating the pupil with the nucleus itself and keeping irrigation above the iris plane, thereby blowing it posterior. I use Viscoat (chondroitin sulfate, sodium hyaluronate, Alcon) to push the iris back and for viscodissection. I like iris hooks better than the Malyugin ring (MicroSurgical Technology), but I have used it and do use both when needed. I also find capsular support hooks helpful in loose zonule cases. I use capsular tension rings and, when needed, segments that are sutured to the sclera. In some cases, placement of two capsular tension rings or a capsular tension ring and a single sutured segment can resolve difficult challenges. Trypan blue capsular dye is helpful in brunescent and white cataracts and also improves the view of angle structures when implanting an iStent (Glaukos).
I like the Mynosys Zepto but prefer a larger capsulorrhexis than is currently available with Zepto, as I primarily do supracapsular phacoemulsification. I will use Zepto more when a larger capsulorrhexis size becomes available. I also like the Iantech miLOOP for nuclear disassembly in dense cataracts. I have used CAPSULaser (Excellens) in animal eyes, and it works well to create a round, strong, centered capsulorrhexis of any size in about a second. I look forward to it being available in the United States.
I did thousands of extracapsular cataract extraction (ECCE) procedures in the past, using an irrigating vectis for nuclear removal. The so-called manual small-incision cataract surgery (MSICS) is an ECCE with an advanced incision design that can be sutureless. I still do some ECCE procedures on very dense lenses and do an incision as taught by the MSICS experts, but in my practice in the U.S., I always place at least one 10-0 Vicryl or nylon suture. While on the topic of sutures, I have found 10-0 Mersilene (polyester) to be nonbiodegradable and permanent, and use it in preference over polypropylene and Gore-Tex when suturing IOL haptics or capsular support devices.
Postoperatively, I use an intracameral injection of moxifloxacin, dexamethasone and ketorolac. I then use only an NSAID for 4 to 6 weeks topically, which can be one drop a day.
While each of these adjuncts requires some additional expense, they are readily available to any surgeon, and the learning curves for surgeon and staff are short. Fortunately, more are on the way, and the ones we have are being continuously improved by innovative surgeons and their industry colleagues.
Disclosure: Lindstrom reports he consults for Alcon, Bausch + Lomb, Zeiss, Johnson & Johnson, Mynosys, Iantech, MST, Omeros and Imprimis.