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Safety and efficacy of intracameral mydriatics in cataract surgery
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Ophthalmology.
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: In order to perform cataract surgery, adequate dilatation of the pupil is essential. This is traditionally achieved by preoperative topical mydriatic eye-drops, commonly cyclopentolate and phenylephrine. This routine has several disadvantages. First, the slow penetration through the cornea delays the onset of mydriasis. Second, the limited bioavailability of topically administered substances with significant systemic absorption may increase the risk for systemic side effects. Third, even if good mydriasis is achieved initially with topical mydriatics (TM), the effect tends to wear off during surgery. In relation to cataract surgery a transient postoperative corneal oedema is sometimes noted, indicating effects on the corneal endothelial pump function. These effects have been ascribed to ultrasonic or mechanical trauma from the phacoemulsification procedure. Corneal endothelial cell loss (ECL) is a commonly studied variable, not least because it is associated with the long-term risk for corneal decompensation. But, there has been a debate whether postoperative corneal swelling after phacoemulsification cataract surgery correlates to ECL.

Aims: To evaluate an alternative mydriatic regimen for phacoemulsification cataract surgery: intracameral injection of mydriatics mixed with lidocaine (ICM). Additionally, to determine the correlation between early transient postoperative corneal oedema and permanent ECL after phacoemulsification cataract surgery.

Methods: Pupil dilatation with ICM (150 µl of lidocaine 1%, phenylephrine 1.5%, and cyclopentolate 0.1%) was compared to TM (phenylephrine 10% and cyclopentolate 1%) prior to cataract surgery. Additionally, two ICM-groups were randomized to receive either 0.6 µg/ml epinephrine added to the irrigating balanced salt solution or no epinephrine in the irrigation solution. Furthermore, two randomized ICM-groups, with or without cyclopentolate, were analyzed. The patients planned for cataract surgery were examined with ultrasonic pachymetry, specular microscope endothelial photography and Orbscan II slit-scan tomography pre- and postoperatively.

Results: With ICM, mydriasis reached 95 ± 3% of its final value within 20 seconds. In the ICM-group, the pupils were smaller than in the TM-group (mean 6.7 ± 1.0 mm versus 7.7 ± 1.0 mm, P<.001), but did not contract intraoperatively as the TM pupils did. Conversely, with ICM the pupil sizes generally increased during the cataract procedures. This increase was significantly greater without epinephrine in the irrigating solution (13 ± 19% versus 4 ± 14%; p = 0.02). No significant differences in pupil sizes were observed between the patients who were given ICM with or without cyclopentolate. The central corneal swelling at the first postoperative day was strongly correlated to the central ECL at 3 months, R2 = 0.785, P < 0.001.

Conclusions: ICM is a rapid and safe alternative to TM in phacoemulsification cataract surgery. An irrigating solution without epinephrine can safely be used with ICM. Cyclopentolate, administrated intracamerally, has no immediate additive mydriatic effect to intracameral lidocaine combined with phenylephrine. The degree of permanent corneal endothelial damage in cataract surgery is reflected in the degree of early postoperative corneal swelling.

Place, publisher, year, edition, pages
Umeå: Klinisk vetenskap , 2008. , 88 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1146
Keyword [en]
Ophtalmology, intracameral, mydriatics, pupil, cataract, phacoemulsification, lidocaine, phenylephrine, cyclopentolate, epinephrine, endothelial cell loss
Keyword [sv]
Oftalmiatrik
Research subject
Ophtalmology
Identifiers
URN: urn:nbn:se:umu:diva-1486ISBN: 978-91-7264-470-0 (print)OAI: oai:DiVA.org:umu-1486DiVA: diva2:141213
Public defence
2008-02-01, Sal B, 1D, Tandläkarhögskolan, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2008-01-11 Created: 2008-01-11 Last updated: 2011-04-08Bibliographically approved
List of papers
1. Intracameral mydriatics in phacoemulsification cataract surgery.
Open this publication in new window or tab >>Intracameral mydriatics in phacoemulsification cataract surgery.
2003 (English)In: Journal of cataract and refractive surgery, ISSN 0886-3350, E-ISSN 1873-4502, Vol. 29, no 12, 2366-2371 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To evaluate intracameral injection of mydriatics in phacoemulsification cataract surgery and compare the results with those of conventional topical mydriatics. SETTING: Department of Clinical Science/Ophthalmology, Umeå University Hospital, Umeå, Sweden. METHODS: This prospective randomized double-blind study included 60 patients who were given topical (topical group) or intracameral (intracameral group) mydriatics. The topical mydriatics comprised 3 drops of cyclopentolate 1% and phenylephrine 10% given 15 minutes apart and 150 microL intracameral lidocaine hydrochloride 1% (Xylocaine) and the intracameral mydriatics, placebo eyedrops and 150 microL intracameral cyclopentolate 0.1%, phenylephrine 1.5%, and Xylocaine 1%. The pupil size was recorded preoperatively, throughout surgery, and 1 day and 1 month postoperatively. Preoperative and postoperative corneal endothelial morphology, corneal thickness, intraocular pressure, visual acuity, aqueous cells and flare, phacoemulsification energy, duration of surgery, pulse, blood pressure, and intraoperative sensation of pain and glare were also recorded. RESULTS: With intracameral mydriatics, mydriasis reached 95% +/- 3% (SD) of its final value within 20 seconds. In the intracameral group, the pupils were smaller than in the topical group (mean 6.7 +/- 1.0 mm versus 7.7 +/- 1.0 mm, P<.001) but did not contract intraoperatively. The pupils in the topical group tended to contract, and the difference between groups was significant (P =.0020). The intracameral group reported less glare during the procedure (P<.001). There was no difference in endothelial cell loss, inflammatory reaction, postoperative corneal swelling, or surgical performance between the groups. CONCLUSIONS: Intracameral mydriatics were a rapid, effective, and safe alternative to topical mydriatics in phacoemulsification. Their use can simplify preoperative routines and in certain high-risk groups, may reduce the risk for cardiovascular side effects.

Keyword
cataract surgery, phacoemulsification
National Category
Ophthalmology
Research subject
Ophtalmology
Identifiers
urn:nbn:se:umu:diva-22318 (URN)10.1016/S0886-3350(03)00522-4 (DOI)14709298 (PubMedID)
Available from: 2009-05-05 Created: 2009-05-05 Last updated: 2010-08-18
2. Postoperative corneal swelling correlates strongly to corneal endothelial cell loss after phacoemulsification cataract surgery.
Open this publication in new window or tab >>Postoperative corneal swelling correlates strongly to corneal endothelial cell loss after phacoemulsification cataract surgery.
2005 (English)In: American Journal of Ophthalmology, ISSN 0002-9394, E-ISSN 1879-1891, Vol. 139, no 6, 1035-1041 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To evaluate postoperative corneal swelling as a predictor of corneal endothelial cell loss after phacoemulsification cataract surgery. DESIGN: Prospective observational case series. METHODS: Thirty patients planned for routine phacoemulsification cataract surgery were included. Ultrasonic pachymetry and specular microscope endothelial photography of the central and nasal portions of the cornea and Orbscan II slit-scan tomography were performed preoperatively and the day after surgery. The 30 patients were selected from 41 patients based on their increase in central corneal thickness: the first 10 cases with a <5% increase, the first 10 with a 6% to 20% increase, and the first 10 with a > or =20% increase. The same measurements were repeated after 1, 2, and 3 months. The primary outcome measures were corneal endothelial cell loss and increase in pachymetry. Several other parameters were also registered, including age, degree of cataract, visual acuity, phacoemulsification time and energy, total operation time, and the amount of infusion fluid used. RESULTS: The central corneal swelling at postoperative day 1 was strongly correlated with the central corneal endothelial cell loss at 3 months (R(2) = 0.785, P < .001). CONCLUSIONS: In this series, with large variations in the corneal swelling at the first postoperative day, the degree of permanent corneal endothelial damage was reflected in the degree of early postoperative corneal swelling. Measuring the difference in pachymetry at postoperative day 1 is a useful way to assess the effects on the corneal endothelium exerted by the phacoemulsification procedure.

Keyword
corneal swelling, phacoemulsification, cataract surgery
National Category
Ophthalmology
Research subject
Ophtalmology
Identifiers
urn:nbn:se:umu:diva-22319 (URN)10.1016/j.ajo.2004.12.080 (DOI)15953433 (PubMedID)744 (Local ID)744 (Archive number)744 (OAI)
Available from: 2009-05-05 Created: 2009-05-05 Last updated: 2010-08-18
3. Intracameral mydriatics in phacoemulsification surgery obviate the need for epinephrine irrigation.
Open this publication in new window or tab >>Intracameral mydriatics in phacoemulsification surgery obviate the need for epinephrine irrigation.
2007 (English)In: Acta Ophthalmologica Scandinavica, ISSN 1395-3907, E-ISSN 1600-0420, Vol. 85, no 5, 546-550 p.Article in journal (Refereed) Published
Abstract [en]

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.

Keyword
phacoemulsification, epinephrine, intracameral mydriatics
National Category
Ophthalmology
Research subject
Ophtalmology
Identifiers
urn:nbn:se:umu:diva-22320 (URN)10.1111/j.1600-0420.2007.00892.x (DOI)17324218 (PubMedID)744 (Local ID)744 (Archive number)744 (OAI)
Available from: 2009-05-05 Created: 2009-05-05 Last updated: 2011-08-26
4. Separate and additive mydriatic effects of lidocaine hydrochloride, phenylephrine, and cyclopentolate after intracameral injection.
Open this publication in new window or tab >>Separate and additive mydriatic effects of lidocaine hydrochloride, phenylephrine, and cyclopentolate after intracameral injection.
2008 (English)In: Journal of cataract and refractive surgery, ISSN 0886-3350, E-ISSN 1873-4502, Vol. 34, no 2, 280-283 p.Article in journal (Refereed) Published
Keyword
intracameral injection, cataract surgery
National Category
Ophthalmology
Identifiers
urn:nbn:se:umu:diva-19989 (URN)18242454 (PubMedID)744 (Local ID)744 (Archive number)744 (OAI)
Available from: 2009-03-13 Created: 2009-03-13 Last updated: 2011-08-26

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