Drop-Free Approaches for Cataract Surgery

Neal H. Shorstein; William G. Myers


Curr Opin Ophthalmol. 2020;31(1):67-73. 

In This Article


Intraoperative iris dilation was first studied by Behndig and associates in 2003.[21] They showed that intracameral injection with a mixture of lidocaine and phenylephrine provided faster, though less maximal, dilation compared with eye drops. This method is now accepted in Sweden as the method of choice.

Shugar[22] in 2006 reported on the benefit of lidocaine–epinephrine in cases of tamsulosin use. Intraoperative phenylephrine injection was also shown to effectively dilate and stabilize iris tone in IFIS.[23,24] Although epinephrine is slightly more effective for intraoperative pupil dilation, it is unstable at neutral pH, which prevents this agent from being a ready-to-use commercial product. Phenylephrine, however, can be formulated and shipped by compounders because of its longer shelf-life. Intracameral phenylephrine achieves a similar effect as topical mydriatics, even with darkly pigmented irides.[25,26]

Preservatives such as benzalkonium chloride, chlorobutanol, and methylparabens should be avoided.[27,28] Epinephrine containing a bisulfite concentration of 0.00625%, however, was found to be safe to the corneal endothelium.[29] This is consistent with previous laboratory studies of perfused endothelium showing no damage below 0.05% bisulfite.

Mydrane (Théa Pharmaceuticals, Keele, UK), a combination of tropicamide, phenylephrine, and lidocaine, is available commercially in Europe. This agent achieved 95% maximal pupil dilation within a mean of 28.6 seconds and remained more stable than the comparison topical group.[30,31]

Omidria (Omeros, Seattle, USA), a combination of phenylephrine and ketorolac, is FDA-approved for intraoperative dilation and control of postoperative pain. This combination agent appears to be superior to a single bolus of intracameral epinephrine for reducing intraoperative and postoperative complications, surgical time, and the need for pupillary expansion devices.[32,33]