Maintenance of mydriasis with one bolus of epinephrine injection during phacoemulsification

Pharmacological pupil dilatation after sinus surgery

Orbital complications after endoscopic sinus surgery are serious problems. Inadvertent contamination of the eye by pharmacological solution can lead to early postoperative anxiety to patients and high concern to surgeons. This is a rare case report of retrograde epinephrine flow through lacrimal duct in sinus surgery with learning tips during postoperative assessment for reassurance in temporary pharmacological effect rather than serious complication.

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].

Subconjunctival 0.1% epinephrine versus placebo in maintenance of mydriasis during vitrectomy: a randomized controlled trial

Background

Pupil dilation and mydriasis maintenance throughout vitreoretinal surgeries are important to allow satisfactory fundus visualization and reduce risk of complications. The purpose of this study is to evaluate the role of subconjunctival epinephrine 0.1% injection in mydriasis maintenance during vitrectomy.

Methods

Ninety-nine consecutive patients undergoing vitrectomy were enrolled. All subjects were preoperatively dilated with tropicamide 1%. Each patient was randomly allocated either in the epinephrine or placebo group. In epinephrine group, patients were submitted to a 0.2 cc subconjunctival injection of a 0.1% epinephrine solution just before first incisions. In placebo group, the same procedure was performed with 0.2 cc of saline 0.9%. Horizontal pupil diameter was measured with calipers before and in the end of the procedure.

Results

Patients in the epinephrine group showed a significantly larger mean pupil diameter in the end of the surgery compared to placebo. There was a significant increase of mean pupil diameter from the beginning to the end of the surgery in such patients. Blood pressure was significantly higher in the epinephrine group than in placebo group. No other adverse effects were noted.

Conclusion

Subconjunctival epinephrine is effective for maintaining and increasing pupil size during vitrectomy, compared to placebo. Caution should be taken regarding intraoperative blood pressure levels.

Trial registration

RBR; RBR-3qzhvg; Registered 8 May 2018—Retrospectively registered, http://www.ensaiosclinicos.gov.br/rg/RBR-3qzhvg/.

[Mechanical pupillary dilatation using rings in small pupils during cataract surgery : Video article]

OBJECTIVE

The purpose of mechanical pupillary dilatation in small pupils is a sufficient visualization of the lens to be able to perform capsulorhexis, phacoemulsification and intraocular lens implantation.

INDICATIONS

The indications for mechanical dilatation are fulfilled in patients where a sufficient pharmacological preoperative pupil dilatation is not possible.

SURGICAL TECHNIQUE

During routine cataract surgery specific foldable rings can be employed to dilate the pupil with the appropriate injector under viscoelastic substances. These rings are carefully placed at the pupillary margin until circular pupillary dilatation up to 6-7 mm is achieved. After intraocular lens implantation and before removing the viscoelastic substance the rings are slowly folded into the injector and then removed. The surgical technique is demonstrated in detail with the help of a video of the operation, which is available online.

RESULTS

Mechanical pupillary dilatation was possible in all patients studied (n = 14), which allowed uncomplicated phacoemulsification and intraocular lens implantation. For both ring systems studied the mean pupillary dilatation was 6.6 mm. At the end of surgery, the pupillary diameter was 4.89 mm using a Malyugin ring (MST, Redmond, Washington, USA) and 4.93 mm with an I‑ring (Visitec, Waltham, MA, USA; P > 0.05). Small lesions at the pupillary margin or pigment dispersion during implantation or explantation depended mostly on the individual patient situation and not on the ring used.

CONCLUSION

Mechanical pupillary dilatation with rings allows sufficient dilatation to perform cataract surgery. Both the Malyugin ring and the I‑ring achieved smooth and atraumatic pupillary dilatation.

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.

Small Pupil--Big Problem: A Management Algorithm

Small pupils pose problems for cataract surgery. The pupil is dilated with topical mydriatic drugs for all cataract surgeries to improve the surgeon's access to, and visualization of, the lens nucleus, cortex, and capsular structures. Limited dilation poses a risk of surgical complications such as iris trauma or tearing of the anterior or posterior capsule. There are many ways and methods to achieve the appropriate pupil dilation, from pre-operative medications to intraoperative pharmacological and/or surgical methods. A management algorithm for small pupil will be discussed in this review. The various methods and maneuvers may work in isolation or combination to achieve adequate pupil dilation.

A paired comparison of intracameral mydriatics in refractive lens exchange surgery

PURPOSE

To compare the efficacy and intra-operative safety of intracameral mydriatics to topical mydriatics in patients undergoing refractive lens exchange (RLE) surgery.

METHODS

In a randomized intra-individually comparing study performed at Koskelas Eye Clinic, Luleå, and Department of Clinical Sciences/Ophthalmology, Umeå University Hospital, Umeå, Sweden, 56 patients undergoing same-day bilateral RLE were included. Pupils were randomly dilated with topical mydriatics in one eye and intracameral mydriatics in the fellow eye. Pupil sizes were recorded intra-operatively throughout the procedures. Perceived pain/discomfort and glare were assessed immediately postoperatively using a visual analogue scale from 0 to 10.

RESULTS

Topical mydriatics and intracameral mydriatics both give satisfactory pupil dilation in routine RLE. However, there was noticeable iris billowing in 17 eyes dilated with topical mydriatics but only one eye with intracameral mydriatics (p < 0.001). Pupils were initially slightly larger in the topical mydriatics group but contracted during surgery. There was no perceived difference with regards to glare, pain or discomfort between the treatments. The surgeon graded intracameral mydriatics eyes as easier to operate on.

CONCLUSION

Both topical mydriatics and intracameral mydriatics give satisfactory mydriasis for RLE, but pupil constriction and iris billowing are more pronounced with topical mydriatics.

Posterior chamber injection of intracameral mydriatics increases the durability of the mydriatic response

PURPOSE

To compare the mydriatic effect of intracameral mydriatics injected into the anterior or the posterior chamber in routine phacoemulsification cataract surgery.

METHODS

Forty-four patients planned for unilateral phacoemulsification surgery were included after informed consent. Mydriasis was achieved by injecting 150 μl of a mixture of phenylephrine 1.5% and lidocaine 1.0% at the beginning of the procedure. The patients were randomly assigned to injection into the anterior or the posterior chamber. The pupils were filmed during the procedures, and the mean pupil diameters were measured at predetermined intervals from the video recordings by an independent observer.

RESULTS

Immediately after the injection, the pupils were larger after posterior chamber injection (3.8 ± 0.8 versus 3.1 ± 0.7 mm; p = 0.004). A similar difference was seen after the phacoemulsification (6.4 ± 0.7 versus 5.9 ± 1.0 mm; p = 0.031). The mydriatic durability was also better after posterior injection (p = 0.004-0.041).

CONCLUSIONS

Apart from immediately after the injection, the initial mydriatic response was similar with both injection techniques, but the durability of the mydriasis was slightly better after a posterior chamber injection of ICM.

Intracameral mydriatics in phacoemulsification cataract surgery -- a 6-year follow-up

PURPOSE

To evaluate the long-term safety of intracameral mydriatics (ICM) in phacoemulsification cataract surgery compared with conventional topical mydriatics (TM).

METHODS

A total of 45 patients were examined 6 years after phacoemulsification cataract surgery. The patients had previously participated in a prospective randomized double-blind study including 60 patients, operated with either ICM or TM. The follow-up included best-corrected visual acuity (BCVA), intraocular pressure (IOP), grade of posterior capsule opacification (PCO), YAG laser capsulotomy rate, pupil size, corneal thickness and endothelial morphology.

RESULTS

No differences in postoperative BCVA, IOP, pupil size, PCO or YAG rate were observed between the groups. Endothelial cell loss, endothelial morphology and corneal thickness were also equivalent.

CONCLUSIONS

Intracameral mydriatics is a safe alternative to topical mydriatics in phacoemulsification cataract surgery with no long-term disadvantages at 6-year follow-up.

An interesting case of a unilaterally dilated pupil

Facial lacerations from minor trauma are a common presenting complaint to the emergency department. With the increasing availability of topical anesthetics, there is a decrease in the need for injectable local anesthetic and sedation services, facilitating the ease of facial laceration repairs for young children. One such topical anesthetic is a widely used pharmacy preparation of lidocaine 4%-epinephrine 0.1%-tetracaine 0.5% gel (LET). Although the use of LET has decreased the need for injectable lidocaine and sedation for facial lacerations, both of which can be unpleasant for children with potentially life-threatening adverse events, it may still lead to unexpected and untoward adverse events. We explore here a little-known adverse effect of LET in a child who presented to a pediatric emergency department with an eyelid laceration after minor head trauma.

Effect of preoperative use of topical prednisolone acetate, ketorolac tromethamine, nepafenac and placebo, on the maintenance of intraoperative mydriasis during cataract surgery: a randomized trial

Purpose:

To compare the effects of preoperative use of topical anti-inflammatory prednisolone acetate, ketorolac tromethamine, nepafenac and placebo, on the maintenance of intraoperative mydriasis during cataract surgery.

Design:

Randomized clinical trial.

Materials and Methods:

This single-center, masked, randomized clinical study comprised 140 patients scheduled for cataract surgery. Patients (35 in each group) were randomized to receive placebo, prednisolone acetate, ketorolac tromethamine 0.4% or nepafenac. These eye drops were administered three times daily for the two days prior to surgery. The pupillary diameters were measured by the surgeon using a compass prior to the corneal section and at the end of surgery. The primary outcome was the number of patients with pupil ≥ 6mm at the end of the surgery; the secondary outcome was the number of patients with pupil ≥ 6mm at the beginning of the surgery.

Results:

All the patients achieved pupil ≥ 6mm at the beginning of the surgery. The number of patients in the prednisolone (29/35), nepafenac (31/35) and ketorolac (30/35) groups with pupil ≥ 6mm was greater than in the placebo group in the maintenance of intraoperative mydriasis (19/35 – P =0.003). There was no statistical difference among the prednisolone, nepafenac and ketorolac groups in the maintenance of intraoperative mydriasis (P =.791). There were no complications during surgery or related to the preoperative use of the eye drops.

Conclusion:

Preoperative use of ketorolac, prednisolone and nepafenac was effective in maintaining intraoperative mydriasis when compared with placebo.

Evaluation of the mydriatic effect of intracameral lidocaine hydrochloride injection in eyes of clinically normal dogs

OBJECTIVE-To evaluate the mydriatic effect of intracameral injection of preservative-free 1% and 2% lidocaine hydrochloride solutions and determine the onset and duration of mydriasis according to the concentration and volume of lidocaine administered in healthy dogs. ANIMALS-5 healthy adult Beagles weighing 7 to 10 kg, with no apparent ocular disease. PROCEDURES-A double-blind randomized 9-session crossover trial was designed. Both eyes were assigned to 9 treatments with a minimum 7-day washout period between treatments: 0.1, 0.2, and 0.3 mL of 2% lidocaine solution; 0.1, 0.2, and 0.3 mL of 1% lidocaine solution; and 0.1, 0.2, and 0.3 mL of balanced salt solution. Dogs were anesthetized, and the allocated treatment was injected intracamerally after aspiration of the same volume of aqueous humor from the anterior chamber of each eye. Two perpendicular pupil diameters were measured. Intraocular pressure, heart rate, respiratory rate, ECG readings, and end-tidal partial pressure of CO(2) were monitored. RESULTS-Intracameral injection of 1% or 2% lidocaine solutions in volumes of 0.1 to 0.3 mL induced a significant degree of mydriasis, and the effect was maintained for 74 to 142 minutes. Lidocaine injection had no significant effect on intraocular pressure, heart rate, respiratory rate, ECG readings, or end-tidal partial pressure of CO(2). CONCLUSIONS AND CLINICAL RELEVANCE-Intracameral lidocaine injection in healthy dogs induced mydriasis, the timing of which was affected by concentration and volume of lidocaine. This technique could serve as an alternative to topically administered mydriatics for intraocular surgery in dogs.

Intracameral mydriatics in phacoemulsification surgery obviate the need for epinephrine irrigation

PURPOSE

To evaluate the possibility of removing epinephrine from the irrigating solution in phacoemulsification surgery when using intracameral mydriatics (ICMs).

METHODS

We carried out a prospective, randomized, double-blinded study of 140 patients with age-related cataracts, scheduled for unilateral phacoemulsification. The first part of the study involved 90 patients divided into two groups. Patients in both groups were given 150 microl ICMs at the beginning of the procedure. In group 1, 0.6 microg/ml epinephrine was added to the irrigating balanced salt solution. No epinephrine was added to the irrigation solution used in group 2. The second part of the study involved 50 patients, all of whom were given topical mydriatics (TMs) and then similarly divided into two groups and treated as in the first study setting.

RESULTS

With ICMs, pupil sizes generally increased during the procedures. Remarkably, this increase was significantly greater without epinephrine (13 +/- 19% versus 4 +/- 14%; p = 0.02). In the TMs setting, pupil sizes decreased intraoperatively in both groups; significantly more without epinephrine (- 5 +/- 4% versus - 12 +/- 7%; p < 0.001).

CONCLUSIONS

An irrigating solution without epinephrine can safely be used with ICMs. The increase in pupil size during the procedure is greater without epinephrine. This study also confirms earlier findings that epinephrine is beneficial when using TMs.

Redilatation with intracameral mydriatics in phacoemulsification surgery

PURPOSE

To determine whether intracameral mydriatics can redilate pupils that contract during phacoemulsification cataract surgery.

METHODS

A total of 80 patients were included in this prospective, randomized, double-blind study performed at Ornsköldsviks Hospital Eye Clinic. Of these, 60 patients had 0.6 microg/ml of epinephrine added to the balanced salt solution (BSS) used for irrigation and 20 patients did not. The patients in each group were randomized and given either an intracameral mydriatics (ICM) solution or placebo intracamerally after phacoemulsification and cortex cleaning. The pupil size was registered preoperatively, after cortex cleaning, 30 seconds after study injection, 2 mins after study injection and the day after surgery.

RESULTS

No clinically relevant differences were found preoperatively. In the epinephrine material a significantly longer operation time (p = 0.023) and more procedures requiring Vision Blue and Kelman-type tip in the placebo group might indicate diversity in the grade of cataract. There was a greater degree of contraction in the absence of epinephrine in the irrigation solution (2.3 +/- 1.0 mm in the ICM group and 3.2 +/- 0.7 mm in the placebo group) compared to in the presence of epinephrine. With no epinephrine ICM significantly redilated the pupils at 30 seconds (p < or = 0.001) as well as at 2 mins (p = 0.015).

CONCLUSION

We have shown that in cases with an intraoperative pupil contraction, ICM is effective in redilating the pupil. Insufficient adrenergic stimulation of the pupil dilator appears to be a major factor causing intraoperative pupil contraction during phacoemulsification cataract surgery.

Effects of intraocular epinephrine on the corneal endothelium of rabbits

Epinephrine is frequently used in the phacoemulsification to dilate pupils. To determine the effects of different concentration of epinephrine on the corneal endothelial cells, twenty-eight rabbit eyes were equally divided into four groups. Solutions, which contained normal saline, 1:1000 epinephrine, 1:5000 epinephrine and 1:10000 epinephrine respectively, were injected into the anterior chambers of the eyes of four groups of rabbits. In vivo morphological changes of corneal endothelium and changes of thickness were checked with specular microscopy. In vitro morphological evaluation of corneal endothelium was observed in excised corneal buttons stained with alizarin red with trypan blue, and with scanning electron microscopy. Our results showed that there was no significant difference in cell density and corneal thickness among the four groups. Alizarin red with trypan blue stain and SEM exam revealed smooth and distinct cell borders of endothelial cells in each group. Intracameral injection of epinephrine does not produce toxic effect on corneal endothelial cells in rabbits.