IV. DILATING DROPS
- Adequate dilation of the pupil prior to cataract surgery is critical in providing the surgeon a good red reflex, the opportunity to create an adequately sized capsulorrhexis, and safer phacoemulsification.
- While a number of different dilating drops can be used, a typical regimen consists of a moderately long-acting anticholinergic agent (eg, cyclopentolate 1% to 2%) and an adrenergic agonist (phenylephrine 2.5%).
- Preoperative atropine 1% combined with intraoperative epinephrine may reduce the risk of intraoperative floppy iris syndrome in patients taking tamsulosin.
- It is best to avoid dilating the patient on the day before surgery if possible, as this can result in suboptimal dilation on the day of surgery (“pupil fatigue”).
- Phenylephrine 10% does not provide additional pupillary dilation compared with phenylephrine 2.5% and should not be used because of the greater risk of cardiovascular side effects.
V. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
There are a number of different FDA-approved topical NSAIDs available for ophthalmic use. Most of these drugs are approved for the treatment of inflammation associated with cataract surgery (Table 3-1) but are also used off-label to help prevent intraoperative miosis, and may also reduce post- operative cystoid macular edema (CME).
- If used for prevention of miosis, it is reasonable to begin instilling the NSAID drops several hours prior to surgery along with antibiotics and dilating agents.
- The routine use of NSAIDs to reduce intraoperative miosis may not be necessary in those cases in which epinephrine is added to the irrigating fluid, but it may be more helpful in patients in whom mechanical dilation of the pupil intraoperatively (posterior synechiae, prior pilocarpine therapy) may be necessary.
- If the goal is to reduce CME, it is better to start using the NSAIDs sev- eral days preoperatively, especially in patients with uveitic cataracts.
Preoperative topical and oral corticosteroids are not indicated for routine cataract surgery. However, in patients with a history of uveitis or scleritis, some combination of these medications may be necessary.
- Patients with uveitic cataracts should defer surgery for at least several months after the uveitis is quiet in order to minimize the chances of a postoperative flare. Some patients will require ongoing corticosteroid therapy or the addition of steroid-sparing immunomodulatory drugs to maintain control of the uveitis.
- One regimen for patients with a history of severe uveitis is as follows:
¤ Begin prednisolone acetate 1% every 2 hours while awake beginning the week before surgery.
¤ Begin oral prednisone 1 mg/kg (up to 60 mg) per day for the 2 days before surgery.
¤ Intravenous Solu-Medrol (methylprednisolone) 62.5 to 500 mg is given at the time of surgery; be sure to clear this with the anesthesiologist prior to starting the operation, as there are potential risks of intravenous corticosteroids.
¤ The oral prednisone is then tapered off or down to the baseline suppressive dose over the first 2 to 6 weeks postoperatively, depending on the degree of inflammation.
VII. MISCELLANEOUS COMMENTS
- A common mistake for the beginning surgeon is to scrub the eyelashes and fornices of patients with blepharitis vigorously during the prep and drape phase of surgery in the hopes of eliminating the problem. Such an approach is actually more likely to increase the bacterial load. Instead, the lashes should be “painted” gently with povidone-iodine solution. One study found that thorough irrigation of the fornix with povidone-iodine was more effective in reducing bacterial counts than simply dripping the solution onto the eye.
- After the prep is completed, the drapes are applied. The sterile drape should be applied so as to completely isolate the lashes of the upper and lower lids from the surgical field. The speculum should then be rotated slightly as necessary to provide unobstructed access of the phacoemulsification probe to the wound.
- In vascularized eyes undergoing scleral tunnel phacoemulsification or combined phacoemulsification/trabeculectomy, the use of preoperative apraclonidine 1% 30 minutes before surgery can help blanch conjunctiva and Tenon capsule.
*Dikutip dari Buku Essentials of Cataract Surgery 2nd Ed, halaman 27-29