Intracameral Group Research Articles

Comparison of pupil dilation in manual small incision cataract surgery using topical versus intracameral mydriatic agents – A randomised controlled trial

Objectives: The purpose of this research is to assess and compare the efficacy of an intracameral mydriatic solution with conventional topical agents in the completion of manual small incision cataract surgery (MSICS) in a black population. Materials and Methods: This randomised controlled trial was conducted among 102 patients undergoing MSICS under sub-tenon’s block. Mydriasis in the topical group was achieved with a pre-operative topical dilating combination of tropicamide 0.8% and phenylephrine 5% while surgery was commenced in patients in the intracameral group without dilation, and mydriasis was achieved intraoperatively with an intracameral solution of lidocaine 0.5% and adrenaline 0.001%. Pupil sizes were measured serially, before, and at four different junctures during surgery. The proportion of patients needing supplementary mydriasis in either group was noted, as well as post-operative pinhole visual acuity (VA). Data analysis was carried out using the Statistical Package for the Social Sciences Statistical Product and Service Solutions(SPSS) version 25.0 (IBM, Chicago, Illinois). The level of statistical significance was set at P < 0.05 at a 95% confidence interval. Results: Mean pupil diameter before dilating and blocking was 2.5 ± 0.6 mm in the topical group and 2.5 ± 0.7 mm in the intracameral group (P = 0.752). This increased to 7.7 ± 1.1 mm and 7.4 ± 0.8 mm, respectively (P = 0.134), after administering either mydriatic agents. After that, mean pupil diameter progressively reduced in both groups but was significantly higher in the intracameral group at each point of measurement (P < 0.05). Postoperatively, there was no significant difference in the VA between the two groups (P < 0.05). Conclusion: Using an intracameral mixture of lidocaine and adrenaline gives adequate mydriasis for the successful completion of MSICS without pre-operative dilation.

Pupil Dilation by Intracameral Injection of Preservative Free 1% Lidocaine and Topical Mydriatics in Phacoemulsification Cases: A Comparative Study

Purpose: To compare the results of pupil dilation by an intracameral injection of preservative free 1% lidocaine with conventional topical mydriatics during phacoemulsification cataract surgery. Comparison was also done for simultaneous anaesthetic effect between intracameral lidocaine and topical mydriatics. Methods: A randomized, comparative interventional study was conducted. The study included 50 patients who underwent phacoemulsification and intraocular lens implantation surgery and were divided in two groups. One group was given topical mydriatics (25 eyes) preoperatively and other intracameral lidocaine (25 eyes) at commencement of surgery to dilate the pupil. The topical group received 3 drops of tropicamide 0.8% and phenylephrine 5% eye drops 15 minutes apart starting 45 minutes before surgery. The intracameral group received preservative-free lidocaine 1% (0.2 to 0.3 mL) injected just before the procedure began. In both groups, the horizontal pupil diameter was measured before and after pupil dilation using the same caliper. Total surgical time, need for a supplement mydriatic agent during the surgery and subjective surgical performance were recorded. Any adverse ocular and systemic effects between two groups were also compared. Results: The mean age, sex, cataract grading, baseline horizontal pupil diameter and mean surgerical time were similar between the topical and intracameral group. The mean pupil dilation was 4.62 ± 0.96 mm in the intracameral group and 4.76 ± 0.75 mm in the topical group. There was no statistically significant difference between the two groups (P value =0.57).There was no significant difference between groups in the overall subjective surgical performance (P=0.72). No patient in any group required supplementary intracameral mydriatic injection. Conclusion: Intracameral lidocaine is a safe, effective and reliable alternative to topical mydriatic for pupil dilation with added advantages of fast postoperative recovery and is also ....

The Optimization of an Anti-VEGF Therapeutic Regimen for Neovascular Glaucoma

This study investigates the safety and efficacy of conbercept injection through different routes for neovascular glaucoma (NVG) treatment, in which seventy-four patients (81 eyes) with NVG caused by ischemia retinopathy had participated. Patients were divided into three stages according to the progression of NVG and were randomly assigned to receive intracameral or intravitreal conbercept injection. After conbercept injection, patients experienced improved best-corrected visual acuity (BCVA), good intraocular pressure (IOP) control, and neovascularization of Iris (NVI) regression. In stage III, patients required trabeculectomy with mitomycin C plus pan-retinal photocoagulation (PRP) to achieve complete NVI regression. Compared to the intravitreal group, the intracameral group had significantly lower IOP in 2 days in stage III and 1 day in stages I and II after injection, complete NVI regression before PRP in stages I and II, and better NVI regression in stage III. The rates of hyphema after trabeculectomy and malfunction filtering bleb suffering needle bleb revision were lower in the intracameral group, but only the hyphema rate was significantly different. Injections through different routes are all safe. We recommend intravitreal injections for patients in stages I and II, but for stage III, intracameral injection is better, and trabeculectomy with mitomycin C should be conducted within 2 days after injection to maximally reduce the risk of perioperative hyphema.Trial Registration: ClinicalTrials.gov, identifier NCT03154892.

Effect of Intracameral Injection of Preservative Free, Fixed Concentration of Combined Mydriatic plus Anaesthetic Formulation on Corneal Endothelial Cell Count in Phacoemulsification

Purpose: To evaluate the efficacy and safety of intracameral injection of a standardized combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1% on corneal endothelial cell count at phacoemulsification. Methods: In this prospective randomized controlled study, 30 eyes of 30 patients undergoing phacoemulsification were assigned to 2 groups. 15 eyes (Intracameral Group A) received 0.2ml of a combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1% just after the first incision. While 15 eyes (Group B) received a topical regimen of one drop of each of cyclopentolate hydrochloride 1% and tropicamide 1%, every 15min for 1hour preoperatively. The main outcome measures were safety on corneal endothelium, by comparing the preoperative and 3 weeks postoperative corneal endothelium cell count in the two groups. Efficacy was also evaluated by measuring pupil size before capsulorhexis and before intraocular lens implantation, in both groups. Results: There was no significant statistical difference in the percentage of endothelial cell loss between the Groups A (27.4%) and the reference Group B (25.7%), with P value (0.595). Regarding Pupillary dilatation, adequate dilatation (>7.4mm) was achieved in both groups. Dilatation was maintained to the end of operation in the Fydrane group, while in the reference group, reduction in pupillary dilatation occurred in 20% (3 cases) reaching pupil diameter 5.5mm before IOL implantation. Conclusions: This study showed that intracameral injection of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1% is safe on corneal endothelium and effective in maintaining pupillary dilatation throughout the surgery

Pharmacologic interventions for mydriasis in cataract surgery

Pharmacologic interventions for mydriasis in cataract surgery

Intracameral mydriatics versus topical mydriatics in pupil dilation for phacoemulsification cataract surgery

To evaluate the efficacy and safety of intracameral mydriatics (lidocaine 1.0% and phenylephrine 1.5%) versus topical mydriatics (phenylephrine 2.5% and tropicamide 1.0%) in pupil dilation for phacoemulsification surgery in Malaysians. Department of Ophthalmology, Penang General Hospital, Georgetown Penang, Malaysia. Prospective comparative case series. Patients with immature cataract were randomized tothe topical mydriatic group (topical group) or intracameral mydriatic group (intracameral group). Patients with small pupilsand complicated cataracts were excluded. Pupil diameterchanges were measured throughout the surgery. Additional pupil dilation maneuvers and complications were recorded. The study comprised 112 patients. There was no difference in mean pupil dilation between the intracameral group (4.86mm±0.74 [SD]) and the topical group (4.88±0.91mm) (P=.86). However, the mean pupil size before capsulorhexis in the topical group (7.23±1.08mm) was significantly larger than in theintracameralgroup (6.40±0.80mm)(P=.01). The pupils in the intracameral group continued to dilate during surgery (0.44±0.62mm), while those in the topical group constricted (-0.41±1.04mm) (P<.001). Three patients in the intracameral group and 6 in the topical group required additional maneuvers for pupildilation (P=.49). Each group had 1 complication (P=1.00). Intracameral mydriatic agents dilated heavily pigmented pupils for phacoemulsification cataract surgery. However, in the early stages of surgery, pupil dilation was slower than with topical agents.

Evaluation of Corneal Endothelial Cell Loss After Uncomplicated Phacoemulsification Cataract Surgery With Intracameral Phenylephrine.

To study the effects of intracameral phenylephrine 1.5% on corneal endothelial cell loss and morphological changes in patients who had uneventful phacoemulsification surgery. A double-blind randomized controlled trial. This study comprised 295 patients who were randomized into the intracameral (ICM) mydriatic group or topical mydriatic group. Central corneal endothelial cell density (ECD), coefficient of variation (CV), and percentage of hexagonal cells were measured preoperatively and postoperatively at 1 week, 6 weeks, and 3 months with specular microscope. There was no significant difference in endothelial cell density and endothelial cell loss between the topical and ICM mydriatic groups. At 3 months, the mean endothelial cell density in the ICM group was 2129.76 ± 423.53 cells/mm2 and 2100.54 ± 393.00 cells/mm2 in the topical group (P = 0.539). The endothelial cell loss was 18.60 ± 12.79% in the IC M group and 19.44 ± 11.24% in the topical group (P = 0.550). No significant difference was seen in the percentage of hexagonal cells and coefficient of variation of patients between the 2 groups. Intracameral phenylephrine was not associated with increased risk of postoperative endothelial cell loss or morphological changes. It can be safely injected into the anterior chamber for pupil dilatation before phacoemulsification cataract surgery.

Efficacy and safety of intraoperative intracameral mydriasis in manual small incision cataract surgery - A randomized controlled trial.

Purpose:The purpose of this study is to assess the efficacy and safety of intracameral mydriatic solution, as compared to preoperative topical mydriatics, in patients undergoing manual small incision cataract surgery (MSICS) under peribulbar anesthesia. To assess the sustainability of intracameral mydriasis in MSICS by monitoring pupil size at specific junctures during the surgery.Methods:This trial recruited 127 patients, who underwent MSICS under peribulbar block. Mydriasis in topical group was achieved with preoperative topical dilating drops while patients in intracameral group were taken up for surgery without dilation, and mydriasis was achieved intraoperatively with intracameral solution. Pupil sizes were measured serially, at six different junctures during surgery. Time duration of surgery, any intraoperative complications and first postoperative day visual acuity, corneal edema score, and anterior chamber inflammation score were noted in all patients.Results:Mean pupil size just before peribulbar block was 7.3 mm in topical group and 3.3 mm in intracameral group (P < 0.001). Mean pupil size in intracameral group increased to 7.3 mm 30 s after injecting intracameral dilating solution. Mean pupil size in both groups progressively reduced, reaching 5.5 mm (topical group) and 6.2 mm (intracameral group) just before intraocular lens implantation (P = 0.001), and measured 5.1 mm and 5.5 mm, respectively, at the end of surgery (P = 0.048). On first postoperative day, there was no significant difference in distribution of corneal edema scores, AC inflammation scores, and in median logMAR visual acuity between the two groups.Conclusions:MSICS can be performed effectively and safely utilizing intracameral mydriatic solution, without the use of preoperative dilating drops.Trial registration:CTRI/2016/06/007036

A comparison of patient pain and visual outcome using topical anesthesia versus regional anesthesia during cataract surgery.

PurposeThe purpose of this study was to compare the level of patient pain during the phacoemulsification and implantation of foldable intraocular lenses while under topical, intracameral, or sub-Tenon lidocaine.Patients and methodsThis was a retrospective study. Three hundred and one eyes subjected to cataract surgery were included in this study. All eyes underwent phacoemulsification surgery and intraocular lens implantation using topical, sub-Tenon, or intracameral anesthesia. The topical group received 4% lidocaine drops, and the intracameral group received a 0.1–0.2 cc infusion of 1% preservative-free lidocaine into the anterior chamber through the side port combined with topical drops of lidocaine. The sub-Tenon group received 2% lidocaine. Best-corrected visual acuity, corneal endothelial cell loss, and intraoperative pain level were evaluated. Pain level was assessed on a visual analog scale (range 0–2).ResultsThere were no significant differences in visual outcome and corneal endothelial cell loss between the three groups. The mean pain score in the sub-Tenon group was significantly lower than that in the topical and intracameral groups (P=0.0009 and P=0.0055, respectively). In 250 eyes without high myopia (< −6D), there were no significant differences in mean pain score between the sub-Tenon and intracameral groups (P=0.1417). No additional anesthesia was required in all groups.ConclusionIntracameral lidocaine provides sufficient pain suppressive effects in eyes without high myopia, while sub-Tenon anesthesia is better for cataract surgery in eyes with high myopia.

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.

Safety of undiluted intracameral moxifloxacin without postoperative topical antibiotics in cataract surgery

The objective of this study is to evaluate the safety of undiluted 0.5% intracameral moxifloxacin for postoperative endophthalmitis prophylaxis in cataract surgery patients without the use of additional postoperative topical antibiotics. All phacoemulsification cataract surgeries performed by a single surgeon (B.A.) at the John A. Moran Eye Center from June 2012 to May 2015 were reviewed retrospectively. From June 2012 to April 2014, patients were given topical 0.5% moxifloxacin postoperatively. From May 2014 to May 2015, all patients were given moxifloxacin intracamerally with no antibiotics postoperatively. The follow-up period was 1month after surgery. Preoperative visual acuity and postoperative visual acuity, corneal edema, and anterior chamber reaction were recorded and compared between the two groups. 384 cataract surgeries were performed during the study period. None of the 384 eyes in the study developed endophthalmitis. Of those 384 eyes, 222 were included in the study for analysis based on the inclusion and exclusion criteria. 131 were part of the topical antibiotic group and 91 were part of the intracameral group. The differences in uncorrected visual acuity at 1day postoperatively (p=0.595) and best corrected visual acuity at 1month postoperatively (p=0.099) were not statistically significant. Differences in corneal edema (p=0.370) and anterior chamber reaction (p=0.069) at 1day postoperatively and corneal edema (p=0.512) and anterior chamber reaction (p=0.512) at 1month postoperatively were also not statistically significant. Undiluted 0.5% moxifloxacin can be safely injected intracamerally following cataract surgery without additional postoperative antibiotic prophylaxis to prevent endophthalmitis without adverse effects on patient outcomes.

Free Radical Content of Drugs Used in Ophthalmology

To evaluate the presence of free radicals in various drugs used in ophthalmology. Twenty five samples of drugs that are used by intracameral or intravitreal route, eleven samples of drugs used as fortified eye drop, thirty samples of topical commercial preparations that are used as long term, and eight samples of autologous serum were analyzed for total free radical presence using a kit for total oxidant status. The highest free radical concentration was in Moxifloxacin (Vigamox) in intracameral group, clindamycin in intravitreal group, brinzolamide in antiglaucoma group. Free radicals are present in drugs used in ophthalmology. The surgeon should consider the risk of oxidative damage in the presence of diseased eye.

The effect of combined topical-intracameral anaesthesia on neuroleptic requirements during cataract surgery

Objective: To evaluate whether the addition of intracameral lidocaine to topical anaesthesia during cataract surgery leads to a decrease in the administration of intraoperative midazolam and fentanyl. Design: Retrospective case-control study. Participants: The eyes of 124 patients undergoing phacoemulsification were included in the study, with 62 in the intracameral group and 62 in the control group. Methods: A single-centre, retrospective chart review of cases between April and October 2007 in which patients had undergone small-incision phacoemulsification with foldable intraocular lens insertion and received preoperatively either topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% (intracameral group) or topical tetracaine 0.5% alone (control group). Intraoperatively, midazolam and fentanyl were administered as needed based on pain and anxiety. Results: A total of 124 eyes (124 patients) were included. There was no statistically significant difference between the mean intraoperative midazolam doses given for the 2 groups ( p = 0.08). The mean intraoperative dose of fentanyl was lower in the intracameral than in the control group ( p < 0.0001). A comparison of intraoperative fentanyl requirements between groups using a multivariate regression analysis for age, gender, surgical time, and preopera-tive fentanyl levels confirmed the lower need for intraoperative fentanyl in the intracameral compared with the control group ( p = 0.0037). There were no anaesthetic complications among any of the study patients. Conclusions: Patients receiving topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% during cataract surgery demonstrated a reduction in intraoperative fentanyl requirements. Surgeons performing cataract surgery under topical anaesthesia should consider the addition of intracameral lidocaine 1% to decrease fentanyl requirements and improve patient safety and comfort.

Preventive Effect Against Post-Cataract Endophthalmitis: Drug Delivery Intraocular Lens versus Intracameral Antibiotics

Purpose: To compare hydrophilic acrylic intraocular lenses (IOLs) as an antibiotic drug-delivery system with intracameral antibiotic administration in terms of the ability to prevent endophthalmitis. Methods: Antibiotic solutions of 0.3% (3 mg/ml) and 0.5% (5 mg/ml) gatifloxacin (GFLX) and 0.5% (5 mg/ml) and 1.5% (15 mg/ml) levofloxacin (LVFX) were prepared. IOLs made of hydrophilic acrylic and silicone were used. Hydrophilic acrylic IOLs were allowed to adsorb the antibiotic solutions. A clinically isolated strain, KOS1, of Enterococcus faecalis was used to induce experimental endophthalmitis in vivo. Antibiotic concentrations were determined with high-performance liquid chromatography (HPLC). Twelve hydrophilic acrylic IOLs with antibiotics were used for the in vitro antibiotic concentration assay. In vivo experiments were conducted with 51 rabbits in total. Antibiotic concentrations in the aqueous humor and effects against bacterial proliferation were evaluated. Results: Concentrations of released antibiotics in vitro were highest on the first day and had decreased by the second day. When a comparison was made between similar initial concentrations, GFLX was released to a significantly higher concentration than LVFX (p < 0.001). In the antibiotic-treated IOL group, GFLX concentrations in the aqueous humor reached a peak at four hours postoperatively and then decreased. The intracameral antibiotic group showed similar tendencies, with a remarkably higher peak concentration. Effects against bacterial proliferation were comparable between the antibiotic-treated IOLs and intracameral antibiotic administration. Conclusions: Preventive effects against endophthalmitis were similar between antibiotic-treated IOL implantation and intracameral antibiotic administration.

Pupil dilation with intracameral lidocaine during phacoemulsification

To evaluate pupil dilation by an intracameral injection of nonpreserved lidocaine 1% during phacoemulsification cataract extraction and compare the results with those using conventional topical mydriatics. Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. A prospective comparative case series study was conducted. The study included 57 patients who were given topical mydriatics (30 eyes) or intracameral lidocaine (27 eyes) to dilate the pupil for phacoemulsification and intraocular lens implantation. The topical group received 3 drops of cyclopentolate 1% and phenylephrine 5% given 5 minutes apart starting 60 minutes before surgery. The intracameral group received preservative-free lidocaine 1% (0.2 to 0.3 mL) injected just before the procedure began. No epinephrine was added to the irrigating solution. In both groups, the horizontal pupil diameter was measured before and after pupil dilation using the same caliper. Total surgical time, need for a mydriatic agent during the procedure, and subjective surgical performance were recorded. The mean age, sex, cataract density, baseline horizontal pupil diameter, and mean duration of the surgery were the same between the topical group and intracameral group. The mean pupil dilation was 4.52 mm +/- 0.08 (SD) in the intracameral group and 4.06 +/- 0.09 mm in the topical group; the difference between groups was statistically significant (P = .001). There was no significant difference between groups in the overall subjective surgical performance (P = .74). No patient in the intracameral group and 2 patients in the topical group required an intracameral mydriatic injection. During phacoemulsification, intracameral preservative-free lidocaine 1% provided rapid, effective mydriasis comparable that of topical mydriatics.

Intracameral mydriatics in phacoemulsification cataract surgery

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 μL intracameral lidocaine hydrochloride 1% (Xylocaine ®) and the intracameral mydriatics, placebo eyedrops and 150 μL 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.