Intraoperative Miosis Research Articles

Acular as a single agent for use as an antimiotic and anti-inflammatory in cataract surgery

Purpose To assess the safety and effectiveness of ketorolac tromethamine 0.5% (Acular®) as a cost-efficient single agent to prevent intraoperative miosis and postoperative inflammation in cataract surgery. Methods Both eyes of 26 patients were randomized to receive Acular preoperatively and postoperatively or flurbiprofen sodium (Ocufen®) preoperatively and prednisolone acetate 1% (Pred Forte®) postoperatively. Time scheduled between procedures was from 2 weeks to 1 month. Pupil dilation was measured preoperatively, intraoperatively, and at the end of surgery. Cell and flare were measured 1 day, 1 week, and 1 month postoperatively. Results A comparison of the Acular and the Ocufen/Pred Forte groups (n=22) showed no statistically significant differences in dilation (preoperative versus postpostoperative) or cell and flare postoperatively. Conclusion Using Acular as a single agent was as effective as the combination of preoperative Ocufen and postoperative Pred Forte in preventing intraoperative miosis and postoperative inflammation in cataract surgery. The use of Acular as a single agent could save the expense of using separate anti-inflammatory and antimiotic preparations preoperatively and postoperatively, enhancing convenience for the surgeon and surgical facility.

Phacoemulsification in eyes with white cataract

Purpose To study the results of phacoemulsification in eyes with white cataract. Setting Aravind Eye Hospital, Madurai, India. Methods This retrospective study comprised 212 consecutive patients with white cataract: 192 mature (90.6%), 11 intumescent (5.2%), and 9 hypermature (4.2%). Patients had phacoemulsification and continuous curvilinear capsulorhexis. After the nucleus was removed by the divide and conquer or the phaco chop technique, a posterior chamber intraocular lens was implanted. Preoperative and intraoperative findings, as well as postoperative outcomes, were analyzed. Results Intraoperative complications included premature entry of the tunnel into the anterior chamber in 4 eyes (1.9%), incomplete capsulorhexis in 60 (28.3%), posterior capsular tear in 4 (1.9%), conversion to a manual nonphacoemulsification technique in 4 (1.9%), intraoperative miosis in 7 (3.3%), and iris chafing in 2 (0.9%). Mean phacoemulsification time was 2.03 minutes (range 0 to 5.8 minutes). A best corrected visual acuity of 6/9 or better was attained in 131 patients (61.8%) on the first postoperative day and in 199 patients (93.9%) at 1 month. Postoperative complications included moderate transient striate keratopathy with corneal edema in 12 eyes (5.7%) and iritis in 2 (0.9%). Conclusion Phacoemulsification was a safe and effective technique to remove white mature cataract in eyes in a developing country.

Conversion from phacoemulsification to extracapsular cataract extraction: Incidence, risk factors, and visual outcome

Purpose: To evaluate the incidence, risk factors, and visual outcome in cases converted from phacoemulsification to routine extracapsular cataract extraction (ECCE).Setting: Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.Methods: A retrospective study was performed in 540 eyes that had clear corneal phacoemulsification performed by an experienced phacoemulsification surgeon. The cases in which phacoemulsification was initiated and then' converted to ECCE were studied. The main parameters evaluated were the factors responsible for the conversion, corneal endothelial cell loss, and visual outcome.Results: Twenty eyes (3.7%) required conversion to ECCE during phacoemulsification. Pupillary miosis (6 cases), posterior capsule rupture (5 cases); prolonged phaco time (4 cases), posterior extension of the capsulorhexis (2 cases), corneal thermal burn (1 case), subluxation of the lens (1 case), and malfunctioning of the ultrasonic handpiece (1 case) were the reasons for the conversion. The mean - percentage of endothelial cell loss was 11.06% ± 2.3 (SD); 18 cases (90.0%) , achieved a visual acuity of 20/40 or better at 6 weeks.Conclusions: Intraoperative pupillary miosis, posterior capsule rupture, and very hard nuclear cataract causing prolonged phacoemulsification were the major risk factors for conversion to ECCE. Optimal preoperative preparation and prompt recognition of complications during phacoemulsification can lead to timely conversion to ECCE to achieve a good visual outcome.

Topical nonsteroidal anti-inflammatory agents in ophthalmology.

Nonsteroidal anti-inflammatory agents or NSAIDs are potent inhibitors of prostaglandin synthesis. As such, they have found many useful roles in ophthalmology. NSAIDs are approved by the FDA to prevent intraoperative miosis during cataract surgery, reduce postoperative inflammation following cataract surgery, and control symptoms of allergic conjunctivitis and pain following refractive surgery. In addition, they have been shown to be effective in preventing cystoid macular edema following cataract surgery or treating cystoid macular edema once it occurs.

Der Irisretraktor nach Holzwig und der Einsatz bei engen Pupillen

The objective was to develop an easy to handle tool for temporary implantation to dilate narrow pupils. High molecular PMMA was used to lathe cut a v-shaped device with sides of 6.9 mm length, 0.8 mm height and 0.4 mm width which opens 7.0 mm. Positioning holes of 0.5 mm diameter are located in the caudal ends of the sides. The HIR was used during cataract extraction in 24 patients with mydriatic-resistant pupils, amblyopia or distinctive macula degeneration. In all 26 cases cataract extraction was made easier due to physiologically dilated pupils. The risk of an intraoperative miosis was effectively eliminated. In two cases removal was difficult as the lower tunnel lip interfered with the removal of the HIR. In comparison with the commercially available devices, the HIR is the simplest, safest and most physiologic alternative.

Ketorolac Tromethamine in the Maintenance of Intraoperative Mydriasis

Mydriatics and antiprostaglandins are routinely applied preoperatively to facilitate the aspiration of cortical material during extracapsular cataract surgery and to prevent intraoperative miosis. Unfortunately, the ideal antiprostaglandin has yet to be introduced. This study represents the first prospective, case-controlled, randomized, masked, clinical trial comparing the efficacy of oral ketorolac tromethamine (KT) with the efficacy of topical flurbiprofen sodium (FS) and a placebo (normal saline) in maintaining intraoperative mydriasis without adrenaline in the irrigation solution. Sixty-three patients, undergoing extracapsular cataract extraction with posterior chamber intraocular lens implantation, were randomly divided into three equal groups. Group 1 received 20 mg of oral KT 2 hours prior to surgery, group 2 received 0.03% FS topical solution at the recommended dosage, and group 3 received topical normal saline in a regimen identical to that of group 2. Identical mydriatics were used in both groups. The patients' pupils were measured at five stages of surgery. The mean pupillary diameters at each surgical stage were greater in group 1 than in group 2; however, the difference was not statistically significant. The pupils in group 3 were significantly smaller than those of group 1 or group 2 (P < .05). No systemic toxicity to KT was observed. Moreover, the need for additional postoperative analgesics was significantly greater in groups 2 and 3. Oral KT is safe, convenient, and as effective as topical FS, and has the added advantage of reducing postoperative pain.

Efficacy of diclofenac sodium solution in reducing discomfort after cataract surgery

Two hundred consecutive patients were enrolled in a randomized, prospective clinical trial evaluating the efficacy of diclofenac sodium (Voltaren Ophthalmic®) in reducing patient discomfort after cataract surgery. Other factors evaluated were the effect of preoperative flurbiprofen (Ocufen®) in preventing intraoperative miosis and on postoperative discomfort and the effect of incision size and intraocular carbachol (Miostat®) on postoperative comfort. Diclofenac significantly reduced discomfort during the first 24 hours after surgery but not two to three days postoperatively, although there was a trend toward reduction. Flurbiprofen given preoperatively did not affect postoperative discomfort. It also did not affect pupil size at the start of surgery but did reduce intraoperative miosis. Incision size (5.2 mm versus 7.0 mm) had no effect on discomfort. Miostat did not affect discomfort, although there was a trend toward more discomfort. The results indicate that topical diclofenac, given immediately after cataract surgery, significantly reduces discomfort during the first 24 postoperative hours.

The influence of the incision lenght on the early postoperative intraocular pressure following cataract surgery

In a prospective study we recorded the early postoperative intraocular pressure of 60 eyes following phacoemulsification and posterior chamber lens implantation. In 30 patients each the implantation either of a folded polyHema intraocular lens through a 3.5 mm incision or of a polymethylmetacrylate intraocular lens through a 7 mm incision was performed. Healon was used in all eyes and thoroughly evacuated from the capsular bag behind the implanted lens and the anterior chamber. For intraoperative miosis 0.5 ml acetylcholine chloride was injected into the anterior chamber after wound closure. Intraocular pressure was measured preoperatively as well as six hours, 18 hours, one week and two months postoperatively without the influence of antiglaucomatous medication. We found no statistically significant change of intraocular pressure at any measurement time in the 3.5 mm group (Student's t-test, p > 0.1). In the 7 mm group only the rise of intraocular pressure at 18 hours was statistically significant (p < 0.05, student's t-test). The comparison of the changes of intraocular pressure from preoperative values between both groups revealed a statistically significant difference at 18 hours (p < 0.05, student's t-test) but not at any other time recorded. Intraocular pressure exceeding 22 mmHg was found at 6 hours in 4 (13.3%) patients of both groups and at 18 hours in 3 (10%) eyes of the 3.5 mm group and 5 (16%) eyes of the 7 mm group (p > 0.1, Fisher's Exact Test). From these results we conclude that 1) regardless of the wound size the pressure rising effect of Healon is successfully counteracted by the aspiration technique described, and 2) with small-incision cataract surgery statistically significant less changes of intraocular pressure are observed in the early postoperative period.

The Effect of 0.1% Indomethacin Eyedrops on Cataract Surgery

Topical use of Indomethacin was documented to prevent surgically induced miosis, and it reduced postoperative inflammatory response. We collected 26 consecutive cataract eyes. Seventeen eyes in the study group received topical 0.1% Indomethacin eyedrops from one day before surgery until two weeks after surgery, in addition to the routine medications. Nine eyes belonging to the control group received the routine medications only. The parameters of our study included the measurement of the pupil diameters in surgery, the central corneal thickness, the intraocular pressure, and the anterior chamber reaction before and after surgery. The results revealed that topical use of 0.1% Indomethacin eyedrops could prevent intraoperative miosis and reduce postoperative corneal edema and anterior chamber reaction, but it did not show much influence on intraocular pressure.

Topical indomethacin prior to cataract surgery reduces intraoperative miosis

Topical indomethacin prior to cataract surgery reduces intraoperative miosis

Evaluation of flurbiprofen-exposed irises to acetylcholine anterior chamber irrigation

Flurbiprofen (Ocufen®), an antiprostaglandin, has been introduced into cataract surgery. It is used to prevent intraoperative miosis by blocking inflammatory mediator formation. Ocufen has been noted to diminish the controlled miosis produced by using acetylcholine in the operative period. This study evaluated the pupillary response to acetylcholine after it had been exposed to Ocufen. This was done using a control versus a study eye in 16 rabbits dilated with phenylephrine hydrochloride and cyclopentolate hydrochloride. The pupil diameters were measured at baseline, then the rabbits' anterior chambers were irrigated with an acetylcholine solution. The resultant pupillary diameters were measured at one and five minutes. At five minutes post-irrigation there was a statistically significant greater constriction in the control group than in the Ocufen group. This implies that Ocufen dampens the iris musculature's response to acetylcholine.

MIOSIS DURING VITREORETINAL SURGERY

Maintenance of wide pupillary dilation during vitreoretinal surgery can be important in successful completion of the operation. This study identified factors associated with intraoperative miosis. Also, flurbiprofen, a topically applied nonsteroidal antiinflammatory agent, was evaluated for its efficacy in preventing intraoperative miosis in a prospective, randomized study of 99 consecutive patients. Factors associated with intraoperative miosis included duration of surgery greater than 90 minutes, preoperative afferent pupillary defect, and recent previous surgery. Preoperative treatment with flurbiprofen did not decrease the risk of intraoperative miosis.

MIOSIS DURING VITREORETINAL SURGERY

Maintenance of wide pupillary dilation during vitreoretinal surgery can be important in successful completion of the operation. This study identified factors associated with intraoperative miosis. Also, flurbiprofen, a topically applied nonsteroidal anti-inflammatory agent, was evaluated for its efficacy in preventing intraoperative miosis in a prospective, randomized study of 99 consecutive patients. Factors associated with intraoperative miosis included duration of surgery greater than 90 minutes, preoperative afferent pupillary defect, and recent previous surgery. Preoperative treatment with flurbiprofen did not decrease the risk of intraoperative miosis.

Flurbiprofen Sodium to Prevent Intraoperative Miosis During Vitreoretinal Surgery

To assess the efficacy of flurbiprofen sodium 0.03% at maintaining pupillary dilation during vitreoretinal surgery, we performed a randomized, double-masked, controlled trial of 139 consecutive patients. The mean decrease in pupil size during surgery in patients who received flurbiprofen was 0.9 mm; for patients who did not receive the drug it was 0.8 mm. The type of surgery performed (vitrectomy or scleral buckle), gender, age, lens status, and a history of diabetes or previous intraocular surgery were assessed and the addition of flurbiprofen to routine preoperative dilation did not significantly affect the mean change in pupil size for any of these subgroups. Of the nine patients who developed at least 3 mm of miosis, five received flurbiprofen and four did not. Use of flurbiprofen did not appear to reduce intraoperative miosis during vitreoretinal surgery in a clinically meaningful manner.