Toxic endothelial cell destruction syndrome after intraocular lens repositioning with intracameral epinephrine

Ocular injury via epinephrine auto-injector

Intraocular injury by epinephrine auto-injector has been rarely reported. Toxic risk to the intraocular structures is suspected, but the evidence is inconclusive. We present the case of a 2-year-old girl who sustained an injury to her right eye by inadvertent epinephrine injection. Cataract surgery was performed to treat an increasingly opaque lens, and an intraocular lens was implanted. The visual outcome was good, with no retinal damage.

Comparison of the effects of 1/10,000 and 1/100,000 concentrations of intracameral epinephrine on corneal endothelium and macular thickness after uncomplicated phacoemulsification

PURPOSE

To evaluate the changes in the corneal endothelial cell parameters and macular thickness after intraocular application of epinephrine [Formula: see text] and epinephrine[Formula: see text].

METHODS

In this study, 210 eyes from 210 patients with age-related cataracts who underwent uncomplicated surgery were included. For all patients, specular microscopy of the corneal endothelium and macular OCT were performed before surgery and 3 months after the surgery. Patients were divided randomly into three groups: without drug (control group), epinephrine [Formula: see text], and epinephrine[Formula: see text]. Three months after the surgery, specular microscopy of the cornea and macular OCT measurements were performed. Measurements were compared between the three groups. Postoperative measurements were also compared with those measurements obtained before surgery.

RESULTS

All the three groups showed a statistically significant decrease in the endothelial cell density after surgery; the reduction in endothelial cell density in the epinephrine [Formula: see text] group was significantly more than those of the other two groups (P value < 0.001). Hexagonality of endothelial cells was significantly reduced in the three groups after the surgery, the epinephrine [Formula: see text] group had more reduction compared with both other groups (P values < 0.001). All the three groups showed a statistically significant increase in the macular thickness after the surgery (P values < 0.001). The mean increase in the macular thickness in the epinephrine [Formula: see text] group was significantly more than those of the other two groups (P values < 0.05).

CONCLUSION

Toxicity of the drug to many endothelial cell parameters and macula was reduced with decreasing concentration of epinephrine to [Formula: see text].

Effect of a Controlled Release of Epinephrine Hydrochloride from PLGA Microchamber Array: In Vivo Studies

This paper presents the synthesis of highly biocompatible and biodegradable poly(lactide- co-glycolide) (PLGA) microchamber arrays sensitive to low-intensity therapeutic ultrasound (1 MHz, 1-2 W, 1 min). A reliable method was elaborated that allowed the microchambers to be uniformly filled with epinephrine hydrochloride (EH), with the possibility of varying the cargo amount. The maximum load of EH was 4.5 μg per array of 5 mm × 5 mm (about 24 pg of EH per single microchamber). A gradual, spontaneous drug release was observed to start on the first day, which is especially important in the treatment of acute patients. Ultrasound triggered a sudden substantial release of EH from the films. In vivo real-time studies using a laser speckle contrast imaging system demonstrated changes in the hemodynamic parameters as a consequence of EH release under ultrasound exposure. We recorded a decrease in blood flow as a vascular response to EH release from a PLGA microchamber array implanted subcutaneously in a mouse. This response was immediate and delayed (1 and 2 days after the implantation of the array). The PLGA microchamber array is a new, promising drug depot implantable system that is sensitive to external stimuli.

Comparative analysis of endothelial cell loss following phacoemulsification in pupils of different sizes

Purpose:

To compare Endothelial cell(EC) loss following Phacoemulsification (PKE) in pupils of different sizes.

Methods:

A prospective double masked observational study in which a total of 150 eyes of 150 patients between 50 & 70 years of age with senile cataract of nuclear sclerosis grade II were enrolled. Patients were allocated into three groups of 50 eyes each in Group A (pupil size <5 mm), Group B (pupil size 5–7 mm) and Group C (pupil size >7 mm). Pupillary size was measured by determining the height of slit on slit-lamp biomicroscope examination. PKE was done by the same expert surgeon using vertical chop technique and a foldable intraocular lens was implanted in the capsular bag. Corneal EC count and pachymetry were performed twice and average of 2 readings was taken for the purpose of this study. Measurements were taken preoperatively and postoperatively on day 1, day 7 and day 30.

Results:

The mean EC count loss on postoperative day 1 in Group A was 19.45%, Group B 14.89%, Group C 10.19% with statistical significant difference between Group A and Group B, as also Group A and Group C. The difference was not significant between Group B and Group C, though there was a fall in EC count in Group C as well. Increase in corneal thickness on postoperative day 1 in group A was 5.43%, Group B 3.55%, Group C 2.14% with statistical significant difference between Group A and Group B, as also Group A and Group C with no difference in Group B and Group C.

Conclusion:

PKE done in eyes with maximal pupillary dilatation of <5 mm causes a greater EC loss and results in thicker corneas postoperatively as compared to eyes with pupillary dilatation of >5 mm at the end of one month.

Mydriatic insert and intracameral injections compared with mydriatic eyedrops in cataract surgery: controlled studies

Mydriatic eyedrops are the standard method for pupil dilation in cataract surgery, but their limitations have prompted a search for alternative techniques. Two alternatives-an ophthalmic insert containing phenylephrine and tropicamide and intracameral injections of various combinations of lidocaine, cyclopentolate, and phenylephrine, with or without epinephrine in the irrigating solution-have been assessed in prospective controlled studies, including randomized controlled trials (RCTs). We reviewed the safety and efficacy of mydriatic ophthalmic inserts and intracameral mydriatic injections compared with the safety and efficacy of mydriatic eyedrops using a systematic PubMed search (1963 to 2014). We identified 9 prospective studies (7 RCTs, 637 patients) of the mydriatic ophthalmic insert and 15 prospective studies (14 RCTs, 1020 patients) of intracameral mydriatic injections; 7 of the RCTs compared intracameral mydriatic injections and mydriatic eyedrops and 7 RCTs studied the optimum intracameral mydriatic injection protocol. The latter showed that a lidocaine and phenylephrine-based solution, without irrigating epinephrine, was optimum for intracameral mydriatic injections. The mydriatic ophthalmic insert and intracameral mydriatic injections were consistently shown to be safe and as effective as mydriatic eyedrops. Each method has distinct advantages and limitations.

FINANCIAL DISCLOSURE

Dr. Behndig has received fees from Théa Pharma GmbH as a member of the European Team for the Prophylaxis of Infection in Cataract Surgery group. Dr. Korobelnik has received consultancy fees from Alcon Surgical, Inc.; Allergan, Inc.; Alimera, Inc.; Bayer HealthCare AG; Carl Zeiss Meditec AG; Novartis Corp.; Roche Innovatis AG; and Théa Pharma GmbH.

Pupil Dilation with Intracameral Epinephrine Hydrochloride during Phacoemulsification and Intraocular Lens Implantation

Objective. To investigate mydriatic effect of intracamerally injected epinephrine hydrochloride during phacoemulsification and intraocular lens (IOL) implantation. Methods. Eighteen cataract patients for bilateral phacoemulsification were enrolled. To dilate pupil, one eye was randomly selected to receive intracamerally 1 mL epinephrine hydrochloride 0.001% for 1 minute after corneal incision (intracameral group), and the contralateral eye received 3 drops of compound tropicamide 0.5% and phenylephrine 0.5% at 5-minute intervals 30 minutes before surgery (topical group). Pupil diameters were measured before corneal incision, before ophthalmic viscoelastic device (OVD) injection, after OVD injection, before IOL implantation, and at the end of surgery. Results. At each time point, the mean pupil diameter in the intracameral group was 2.20 ± 0.08, 5.09 ± 0.20, 6.76 ± 0.19, 6.48 ± 0.18, and 5.97 ± 0.24 mm, respectively, and in the topical group it was 7.98 ± 0.15, 7.98 ± 0.15, 8.53 ± 0.14, 8.27 ± 0.16, and 7.93 ± 0.20 mm, respectively. The topical group consistently had larger mydriatic effects than the intracameral group (P < 0.05). The onset of mydriatic effect was rapid in the intracameral group. There was no difference in surgical performance or other parameters between groups. Conclusions. Intracameral epinephrine hydrochloride appears to be an alternative to the mydriatic modalities for phacoemulsification and IOL implantation. In comparison with topical mydriatics, intracameral epinephrine hydrochloride offers easier preoperative preparation, more rapid pupil dilation, and comparable surgical performance.

Phacoemulsification without preoperative topical mydriatics: induction and sustainability of mydriasis with intracameral mydriatic solution

Context:

Intracameral mydriatic solution can eliminate the disadvantages of repeated eye drop instillation regimen and provide adequate mydriasis for phacoemulsification with added advantages.

Aims:

Evaluating the role of intracameral irrigating solution (0.5% lignocaine + 0.001% epinephrine) in initiating and maintaining the pupillary mydriasis during phacoemulsification. Secondary aims were to observe the effect of surgical time, nucleus density and ultrasound time on mydriasis during the procedure.

Settings and Design:

The study is a prospective interventional case series, conducted at tertiary care institution.

Materials and Methods:

Thirty patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Pupillary dilatation was achieved by intracameral irrigation of mydriatic solution alone. Pupillary diameter was measured serially during surgery and ultrasound time and total surgical time were noted.

Statistical Analysis Used:

Paired samples student–t test was done to compare means. Spearman correlation coefficient was used to study the effect of various parameters on mydriasis.

Results:

Thirty eyes completed the study. The pupil size increased from 2.1 mm (Range 2-3.5 mm SD ± 0.32) to 6.9 mm (Range 5-9 mm SD ± 1.02) in 30 seconds time after intracameral mydriatic solution delivery, and was 7.0 mm (Range 3.5 - 9 mm SD ± 0.20) at the end of surgery. Duration of surgery, grade of nucleus and ultrasound time had statistically insignificant effect on mydriasis.

Conclusions:

Intracameral solution containing 0.5% lignocaine and 0.001% epinephrine provides rapid mydriasis which is adequate for safe phacoemulsification and is unaffected by other parameters.

Intraoperative floppy-iris syndrome

OBJECTIVE

Intraoperative-floppy iris syndrome (IFIS) has been recently described. It has been demonstrated that this new syndrome complicates cataract surgery. In this paper we have reviewed the syndrome, and offer practical information specially related to the origin and management of this syndrome and we offer practical information.

MATERIAL AND METHODS

A review of the related medical literature using PubMed and Cochrane databases. Combining the search terms tamsulosin, cataract, IFIS and intraoperative floppy iris syndrome, more than 200 articles were found. Eighty-two of them were obtained and analysed. In the remaining only the abstract could be studied.

RESULTS

The aetiological association between IFIS and tamsulosin (and to a lesser degree between IFIS and other alpha-antagonists) is well established. Other aetiological associations are doubtful. Most of the literature is centred on cataract surgery. However, a similar syndrome has been described during trabeculectomy. A possible association between these drugs and choroidal detachments has also been described. Undoubtedly tamsulosin treatment makes cataract surgery more difficult and increases the probability of intraoperative complications. Protocols to manage the syndrome have not yet been developed. Intracameral injection of alpha-adrenergic agonists seems to be useful. However there is no evidence of the usefulness of discontinuing the drug or using preoperative mydriatics.

CONCLUSION

The aetiological and clinic features of the syndrome are well established. More studies are needed to provide scientific evidence on the most appropriate way to cope with this syndrome.

Pediatric intraoperative floppy iris syndrome associated with persistent pupillary membrane

Intraoperative floppy iris syndrome (IFIS) occurring during cataract surgery in adults has been widely reported in association with tamsulosin and other α-1(a) adrenergic antagonists; however, only one case of pediatric IFIS has been previously reported and was associated with congenital cataract. We report a case of a 1-month old girl with IFIS associated with bilateral persistent pupillary membranes without cataracts and the use of preoperative topical phenylephrine and pilocarpine for IFIS prophylaxis.

Comparison of the influence of intracameral gentamicin, gatifloxacin, and moxifloxacin on the corneal endothelium in a rabbit model

PURPOSE

To compare the effect of three intracameral antibiotics, gentamicin (GM), gatifloxacin (GFLX), and moxifloxacin (MFLX), on the rabbit corneal endothelium.

METHODS

Twenty-four eyes from 18 rabbits were used. In the GM treatment group of 12 eyes, a dose of 20 mg/ml, 2 mg/ml, 200 μg/ml, or 20 μg/ml of GM was injected into the anterior chamber. In the GFLX and MFLX treatment groups were injected into the anterior chamber of three eyes. The central corneal thickness was measured. The eyes were then enucleated for observation under scanning electron microscopy.

RESULTS

Three days after the intracameral injection, a significant difference in central corneal thickness was found between the GM 20 mg/ml group and the control group (P < 0.05), but not between any other groups. The damage rate at the endothelial cell level was 67% in the GM 20 mg/ml group, 56% in the GM 2 mg/ml group, 33% in the GM 200 μg/ml group, 22% in the GM 20 μg/ml group, 22% in the GFLX group, and 0% in the MFLX group.

CONCLUSIONS

Intracameral GFLX or MFLX was almost nontoxic to the rabbit corneal endothelium, in contrast to the toxic results of intracameral GM 20 and 2 mg/ml.