Full text of DOI:10.1089/108076801750295281

JOURNAL OF OCULAR PHARMACOLOGY
AND THERAPEUTICS
Volume 17, Number 3, 2001
Mary Ann Liebert, Inc.
Maintenance of Mydriasis with One Bolus of
Epinephrine Injection During
Phacoemulsification
SHIOW-WEN LIOU and CHUN-CHEN CHEN
Taipei Medical University, Department of Ophthalmology, Municipal Jen-Ai Hospital,
Taipei, Taiwan, Republic of China
ABSTRACT
Surgically-inducedmiosis commonly occurs during cataract extraction surgery, com-
plicating removal of lens cortex and placement of a posterior chamber intraocular lens.
To maintain intraoperative mydriasis, one bolus of epinephrine injection was used in our
study. The pupillary response to various doses of intracameral epinephrine (0.1 ml of
1:25,000, 1:50,000, 1:100,000, 1:200,000, 1:400,000) was assessed in 60 consecutive pa-
tients. The pupil size was measured just prior to the incision, one min after epinephrine
injection, after phacoemulsification and after irrigation/aspiration. There was no signifi-
cant difference among the mean mydriatic responses to the epinephrine concentrations we
tested. The 1:400,000 concentration appeared to be as effective as 1:25,000, but two cases
of the 1:400,000 group failed to maintain the pupil diameter after irrigation/aspiration. In
addition, we found that blood pressure did not elevate after injection of any concentra-
tion of epinephrine. We concluded that one bolus of an extremely dilute concentration of
epinephrine (i.e., 1:400,000) injection might be effective in maintaining mydriasis during
cataract surgery without systemic side effects.
INTRODUCTION
Surgically-induced miosis during phacoemulsification has been demonstrated to be the major
cause of complications, such as iris damage, incomplete cortex removal, and posterior capsule rup-
ture (1). Cataract extraction is performed more easily if mydriasis can be maintained until the in-
traocular lens has been inserted (2). Furthermore, postoperative inflammation would be less severe if
the iris were not disturbed during lens manipulation. Intracameral irrigation with epinephrine may be
of benefit in this respect (3). However, systemic absorption of epinephrine during the operation may
cause systemic side effects, such as elevated heart rate and blood pressure (4). Moreover, several stud-
ies reported that intracameral injection of high concentration epinephrine might lead to corneal injury
(5–7). The purpose of the present study was to investigate the lowest concentration of epinephrine
which was effective in maintaining pupil size during cataract surgery, and to evaluate its influence
on heart rate and blood pressure.
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MATERIALS AND METHODS
Sixty consecutive patients who underwent phacoemulsification by one surgeon were included in
this study. A written informed consent was given to every patient. There were 28 males and 32 fe-
males; their mean age was 69 years (range 55 to 83 years). The sixty study cases were assigned ran-
domly into 5 groups with different concentrations of epinephrine injection (1:25,000, 1:50,000,
1:100,000, 1:200,000, or 1:400,0000, respectively). The background of the five different groups of
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patients was: group 1: 6 males and 5 females, mean age was 67 1.1; group 2: 7 males and 6 fe-
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6
males, mean age was 71 0.9 ; group 3: 4 males and 6 females, mean age was 66 1.5; group 4:
6
6 males and 8 females, mean age was 68 1.3; and group 5: 5 males and 7 females, mean age was
6
70 1.0. One drop of the topical 0.5% tropicamide, which was about 2.5 mm in diameter, was ad-
ministered to every patient half an hour before surgery, ten min before surgery and five min before
surgery. Horizontal pupil diameters were measured with calipers under standard illumination of an
operating microscope. The depth of anterior chamber was maintained normal during measurements
to minimize optically-induced errors. Pupil size, heart rate and systolic/diastolic blood pressure were
measured by the surgeon just prior to the initial incision at surgery, one min after intracameral in-
jection of epinephrine, after phacoemulsification and after irrigation/aspiration (I/A). One bolus in-
jection of 0.1 cc epinephrine into the anterior chamber directly over the center of the pupil was per-
formed in all cases. The 1:25,000 concentration was prepared by adding 0.2 cc of 1:1,000 epinephrine
to balanced salt solution to reach 5 cc. The other concentrations were made by diluting the 1:25,000
preparation. The control group (10 eyes) received the same amount of injection. The mean time of
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operation was 31 1.6 min in the study group and 30 2.0 min in the control group. Data were an-
,
alyzed with the paired or unpaired ANOVA test. P 0.05 was considered statistically significant.
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RESULTS
Sixty patients were enrolled in the study, with no excluded cases. There was no significant dif-
ference in pupil size between the study and control groups before the initial incision. Pupil size re-
mained stationary during the operative procedures in the five study subgroups; progressive miosis
was noted in the control group (Table 1). Therefore, postphacoemulsification and post I/A pupil sizes
were significantly greater in the study group regardless of epinephrine concentration compared with
the control group (Table 1). However, there was no significant difference in pupil size among the five
different epinephrine concentrations (Table 1).
There was no significant change in heart rate and blood pressure (systolic and diastolic) during
the operation in the study and control groups (Tables 2–4). There was also no significant difference
in heart rate and blood pressure (systolic and diastolic) between the study and control groups (Tables
2–4).
DISCUSSION
Phacoemulsification is a major technique in the treatment of cataract, but pupillary constriction
during the operation may not only hinder the progress of surgery, but also result in iris damage, in-
complete removal of nucleus and cortex and, most seriously, posterior capsule rupture and loss of
lens material into the vitreous (1). Thus, maintenance of mydriasis is important to improve the ease
with which surgery can be performed and to avoid complications.
Previous studies have shown that intracameral irrigation with I/A fluid containing 1:1,000,000
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epinephrine is a safe and effective means of maintaining mydriasis during cataract surgery (3). How-
ever, this procedure has potential disadvantages, including prolonged exposure of the anterior seg-
ment to epinephrine and its preservative, and less control over the total amount of drug administered
(since this is governed by the amount of infusion necessary for the surgical procedure) (8). Thus,
some surgeons have advocated a bolus injection of epinephrine into the anterior chamber. Neverthe-
less, early experience with intraocular infusion of 1:1,000 epinephrine resulted in a few cases of se-
In vitro
vere corneal decompensation (9).
studies of functional and morphological changes in animal
corneas have also shown corneal swelling and endothelial damage after perfusion with commercial
epinephrine 1:1,000. Because of potential toxicity of intraocular epinephrine infusion, dose-response
data are necessary for determining the minimal effective dose without increasing the risk of corneal
endothelial damage.
The results in the present study demonstrate that pupil size remained stationary during the op-
eration in patients receiving intraocular epinephrine injection regardless of epinephrine concentration;
in contrast, progressive miosis was noted in the control group. Furthermore, maintenance of mydria-
sis during surgery was similar between 1:400,000 and 1:25,000 epinephrine. However, we found that
pupil diameter began to decrease in the 1:400,000 group during irrigation/aspiration. The decrease
.
was not statistically significant (p 0.05).
Theoretically, systemic absorption of epinephrine infused into the eye can potentially occur both
via
via
the nasolacrimal duct from overspill into
the vascular structures of the anterior segment, and
the conjunctival sac (3,4). In the present study, there were no significant changes in heart rate and
blood pressure (systolic and diastolic) during the operation in patients receiving intracameral epi-
nephrine injection.
Some authors have advocated the addition of epinephrine to the bottle of irrigation solution to
maintain mydriasis during phacoemulsification (3). Advantages of this procedure include the elimi-
nation of an additional intracameral injection, and the use of extremely diluted epinephrine. Potential
disadvantages include prolonged exposure of anterior segment tissue to epinephrine and its preserv-
ative, and less control over the total amount of drug administered.
Epinephrine maintains mydriasis by a direct action on the dilator pupillae of the iris. In addition,
mechanical stimulation of the iris by lens materials or instruments during surgery may lead to release
of prostaglandins causing pupillary constriction. Therefore, some studies have used nonsteroidal anti-
inflammatory medications, such as indomethacin (10–13), flurbiprofen (12,13), diclofenac (14) and
suprofen (15) to inhibit miosis during surgery, but they did not maintain mydriasis as effectively as
epinephrine infusion.
In conclusion, a single bolus injection of an extremely diluted concentration of epinephrine
(1:400,000) is a safe and effective means of maintaining mydriasis during phacoemulsification with
posterior chamber lens implantation, without significant influence on heart rate and blood pressure.
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Received: July 31, 2000
Accepted for Publication: January 3, 2001
Reprint Requests: Shiow-Wen Liou, M.D., Ph.D.
Department of Ophthalmology
Taipei Municipal Jen-Ai Hospital
10 Sec. 4, Jen-Ai Road
Taipei, Taiwan, ROC
E-mail: swanliou@pcmail.com.tw
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