A large, stable pupil makes cataract surgery 10 times easier, so the bigger a patient's pupil is dilated, the better. While every patient gets pre-op drops to do the job, if you do enough cases, you'll likely see at least one difficult pupil every day. For those cases, you can turn to the drugs and devices that open stubborn pupils.

• Dilating drugs. If enough time passes after the administration of pre-op drops and a patient still isn't dilated as well as we'd like — maybe the Flomax he's taking for his prostate is causing intraoperative floppy iris syndrome, maybe she's diabetic or suffers from pseudoexfoliation — we have several other pharmaceutical agents we can try.

Some phenylephrine formulations can cost hundreds of dollars for a single dose, while preservative-free ephinephrine and lidocaine can be compounded with balanced salt solution to create 'Shugarcaine' for 8 patients at a total cost of about $35. While you'll notice the pupil shrinking during the course of a case, you'll want it to be at its largest for the capsulorhexis. Which means it'll be more effective to start off with a bolus of epinephrine, as Shugarcaine offers, than to dose small amounts of it throughout, as some formulations do.

• Mechanical solutions. If the pharmaceutical options don't deliver dilation, mechanical options can safely expand the iris to increase the field of view and improve access to the lens. Fifteen to 20 years ago, we had iris hooks, which gently stretched the pupil, but implantable iris rings have been a game changer. No matter how small the pupil is, they're guaranteed to hold it open to a workable size. While I've found I rarely require expansion rings, they can get you though a worst-case scenario, so you should have them on hand for every case.

These rings and their workings look similar, but there are 2 key areas of difference between them. Depending on the number of points of contact with the margins of the iris, some rings may make the dilation more round and others more square. In addition, each has its own insertion and removal device. Some physicians may find that a particular device, and its unique manner of operation, works better than others. This could be a critical deciding factor. While they can probably get comfortable working with any ring during a case, the ability to easily insert and remove that ring is essential to an efficient process. OSM

Akorn
Phenylephrine Hydrochloride Ophthalmic Solution
akorn.com
(800) 932-5676
Pricing: not disclosed
FYI: Akorn's entry into the phenylephrine hydrochloride market is available in 3 configurations: the 2.5% solution in a 2 mL or 15 mL vial, and the 10% solution in a 5 mL vial. The product does not require refrigeration and has an unopened shelf life of 24 months. Applied topically (1 drop per 3 to 5 minutes up to a maximum of 3 drops), the solution enacts maximum dilation in 20 to 90 minutes, with recovery following 3 to 8 hours after dosage.

ASICO
Beehler Irrigating Pupil Expander
asico.com
(800) 628-2879
Pricing: $966
FYI: The Beehler expander is able to fit through a 2.5 mm incision, making it ideal for use in clear corneal incision procedures. It features a pair of flexible, U-shaped retractors that engage and expand the pupil in a triangular shape. The built-in port enables continuous irrigation and allows physicians to lessen their use of viscoelastic.

Beaver-Visitec International
I-Ring Pupil Expander
beaver-visitec.com
(866) 906-8080
Pricing: $120 to $125 each, pricing incentives for 6-pack
FYI: Made from pliable polyurethane and designed with rounded channels, the I-Ring gently and uniformly retracts the iris to allow a 6.3 mm diameter field. Placement and removal of the sterile, single-use device can be accomplished single-handedly with the included inserter, and its positioning holes ensure that the Sinskey hook used to engage and disengage the channels won't injure the iris.

Diamatrix
XpandNT Iris Expansion System
diamatrix.com
(800) 867-8081
Pricing: Starter kit, $1,500; iris speculum, $250 each
FYI: The low profile and 8 fixation points of the XpandNT Iris Speculum provides 6.75 mm of consistent mechanical dilation with minimal trauma. The multi-use device, validated for up to 5 uses, is injected through a 2.4 mm or larger incision. Diamatrix's XpandNT starter kit includes 4 of the reusable rings, 2 injectors, 2 manipulators and 2 sterilization trays. The company plans to launch a disposable expansion ring ($100 each) at the ASCRS conference in May.

Eagle Vision
Graether 2000 Pupil Expander
eaglevis.com
(800) 222-7584
Pricing: $95
FYI: The Graether 2000 Pupil Expander is a silicone ring that dilates difficult-to-manage pupils into a 6.3 mm opening. A redesigned insertion instrument allows single-handed operation for controlled release and accurate placement of the device through the phaco incision. The expansion ring is provided pre-loaded and sterile in the insertion instrument.

MicroSurgical Technology
Malyugin Ring
microsurgical.com
(888) 279-3323
Pricing: $125
FYI: The Malyugin Ring's 8 points of fixation ensure not only a round and dilated pupil (6.25 mm and 7 mm sizes are available), but also less risk of damage to the iris sphincter. While the device has traditionally required an incision of at least 2.2 mm for insertion, MicroSurgical Technology says it will soon roll out the Malyugin Ring 2.0, which needs 0.2 mm less. The single-use rings are provided sterile with disposable injectors for placement and removal, and the reusable Osher Malyugin Ring Manipulator is also available from MST.

Oasis Medical
Iris Expander
oasismedical.com
(800) 528-9786
Pricing: not disclosed
FYI: Designed to cradle iris tissue without pinching or clamping, the 4 pockets of Oasis Medical's molded polypropylene expansion ring provide intraocular access and visibility when inadequately dilated pupils complicate surgery. The sterile, single-use devices are available in 6.25 mm and 7 mm pupil sizes, and the company's specially designed disposable inserter is pre-attached to the ring inside of protective packaging.

Omeros Corporation
Omidria (phenylephrine and ketorolac injection) 1% / 0.3%
omidria.com
(844) 663-7671
Pricing: $465 per vial. CMS reimburses this pass-through status product separately from bundled cataract surgery payments when billed under the code C9447. For more information, visit omidria.com.
FYI: A new spin on topical dilation agents, Omidria combines phenylephrine and ketorolac to reduce inflammation and post-op pain as it consistently widens the pupil. The solution, provided in a single-patient-use 4 mL vial, is added directly to the balanced salt solution used for intraoperative irrigation, delivering predictable procedures and smoother recoveries without requiring surgeons to change their techniques, says the company.

Paragon BioTeck
Phenylephrine Hydrochloride Ophthalmic Solution
paragonbioteck.com
(888) 424-1192
Pricing: not disclosed
FYI: Paragon BioTeck's phenylephrine hydrochloride ophthalmic solution, supplied to wholesalers by Valeant Pharmaceuticals, constricts ophthalmic blood vessels and the muscles of the iris to deliver peak dilation 20 to 90 minutes after topical administration, with recovery after 3 to 8 hours. The product is available in a 2.5% solution (in a 15 mL vial) and a 10% solution (in a 5 mL vial), and requires refrigeration.