Does [pupil] size matter? How premium surgeons can avoid the inevitable

Every day when a premium surgeon enters the operating room to perform ophthalmic surgery, pupillary dilation — the portal to the operative field — will inevitably have a major stake in the success and outcome of the surgery. As a cataract surgeon, I am amazed how often intraoperative miosis and/or small pupils at the outset of a case can wreak havoc for even the most experienced anterior segment surgeons.As we know, intraoperative miosis is frequently unpredictable or may be associated with conditions such as intraoperative floppy iris syndrome associated with systemic use of alpha-1 adrenergic antagonists (all ending with –osin), pseudoexfoliation syndrome, diabetes mellitus, prior history of uveitis, prior history of trauma or intraocular surgery, and most recently femtosecond laser-assisted cataract surgery (FLACS). Pupil size does matter, and a well-known colleague of mine, Johnny L. Gayton, MD, once reminded me that “pi r squared,” or the area of a circle, is probably the geometry lesson I slept through in high school. Intraoperative pupillary diameter, if starting at a 6-mm diameter, is reduced to 3.5 mm during surgery; this reduction represents a 66% reduction in operative viewing field for the surgeon. And most of us know what can happen next — a visit to our cardiologist postoperatively.