To evaluate the efficacy, safety, and cost implications of using epinephrine (Epi) as an additive in balanced salt solution (BSS) during cataract surgery, focusing on intraoperative pupil dilation, side effects, and cost considerations.

Searches were conducted across multiple databases, including EMBASE, MEDLINE, CINAHL, and Web of Science, up to October 17, 2024. Eligibility criteria included studies assessing intracameral epinephrine for achieving or maintaining mydriasis, and reporting outcomes related to efficacy, adverse effects, intraoperative complications, and cost implications.

Of the 476 articles screened, 23 met the inclusion criteria, involving 4262 cataract surgeries were included. Intracameral epinephrine consistently maintained pupil dilation, with reported average pupil sizes ranging from 6.9 mm to 7.2 mm, significantly reducing the need for additional mechanical dilation interventions (reported incidence <1% in some studies). Its use reduced the incidence of intraoperative floppy iris syndrome (IFIS) in high-risk patients. It minimized complications such as posterior capsular rupture and iris prolapse. Combination therapy with adjunctive agents like NSAIDs or lidocaine further improved dilation stability and reduced intraoperative miosis. Safety data revealed no significant impact on heart rate or blood pressure, demonstrating hemodynamic stability. Cost analyses highlighted savings from reduced surgical times (i.e., ∼13.5 min vs. ∼17.2 min with epinephrine alone) and decreased use of pupil expansion devices, resulting in estimated savings of over $19,000 in high-volume centers.

Intracameral epinephrine effectively supports stable pupil dilation and reduces intraoperative complications in cataract surgery. It offers a safe and cost-effective alternative to traditional mydriatic agents, particularly when combined with adjunctive medications. However, given the considerable advancements in surgical techniques over time, caution should be exercised when interpreting findings from earlier studies. Additionally, the cost of epinephrine preparation, alongside its potential endothelial toxicity at higher concentrations, highlights the need for further research into the feasibility of using BSS without epinephrine in routine practice.