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MIOTICS in CATARACT SURGERY by Harold Beasley, MD

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MIOTICS in CATARACT SURGERY by Harold Beasley, MD MIOTICS IN CATARACT SURGERY BY Harold Beasley, MD PROMPT MIOSIS OF the pupil after delivery of the lens in round pupil cataract surgery is recommended to protect the vitreous face, to prevent iris incarceration, and to facilitate the postplacement of corneoscleral sutures.1 It has been postulated that miosis also prevents the formation of peripheral anterior synechia, but this has not been demonstrated experimentally.2 An ideal miotic should produce prompt pupillary constriction and for a duration of 12 to 24 hours. It should also be nonirritating to anterior chamber structures. Acetylcholine ( 1.0 per cent)37 and a weak solution of carbachol (0.01 per cent) ,8 as well as pilocarpine, have been found to be satisfactory for this purpose. The purposes of this study were (1) to evaluate the effectiveness of miotics in preventing peripheral anterior synechia and in preserving the integrity of the vitreous face; and (2) to compare the effectiveness of acetylcholine 1 per cent and carbachol 0.01 per cent as miotics in round pupil cataract surgery. PROCEDURE This study compared three experimental treatments in a double blind procedure in which the code was left unbroken until all the data were accumulated. Selected patients were gonioscoped prior to surgery and only patients with grades Im or iv angles were chosen for this study. All patients were predosed with 2 per cent homatropine and 10 per cent phenylephrine. Prior to the injection of the test solution the pupillary diameters were measured before the section was made and immediately after lens extraction. Measurements were then made at two minutes and at five minutes after the intracameral instillation of 0.4- to 0.5-cc of the test solutions. Most of the pupils were also measured 15 hours after treatment. The pupils were measured with a caliper in the horizontal and vertical diameters and average pupillary diameters were computed for each patient at each of five times, as indicated. The surgery, observa- TR. AM. Opm. Soc., vol. 69,1971 238 BeasleyJ tions, and measurements were all performed by the writer. The vitreous face was observed with the slit lamp at the fourth and twenty-first post- operative days and at the seventh postoperative week, and was graded as either intact or broken. Gonioscopic examinations for the presence of peripheral anterior synechia were done at the seventh postoperative week. TREATMIENTS The three treatments consisted of 0.01 per cent carbachol, 1 per cent miochol, and for control, balanced salt (BSS) solutions, in uncomplicated round pupil cataract extractions. Each individual in the sample of 121 private patients was assigned randomly to one of the three treatment groups. Table 1 summarizes the number of cases and descriptive in- formation on the composition of the three groups. Although the number of cases assigned to the miochol group was lower than the other two, TABLE 1. AGE AND SEX CHARACTERISTICS OF THE THREIE' TREATIMENT GROUPS. THE P'ROPORTION WN'ITH EACH EYE' INVOLVED, AND THE NUMIBI,ER TREATIE,D WITH ENZYM.\IE Carbachol AMiochol BSS 0.01 per cent 1.0 per cenit control Number of cases 44 1)4 4:3 Sex-per cent mlale 32 59 1:7 Age-miean yrs 66. 9 65..) 68.9 SD 9).9 9.4 8.7 Es-e treated-percent OD 59 -() 53: Enizyme-per cenit uise 50 69 42 this apparently reflected an idiosyncrasy of operating room procedure and no systematic selection bias. The samle comment applies to the higher percentage of men in the miochol group. It should be noted that no relationship was expected between the sex of the patient and the surgical results. With respect to age, which is a more important factor, the three groups were well matched, both in mean age and dispersion. Differences in the percentages of either eye involved were not significant. The difference in per cent using enzyme was greater than intended, but the effect of this difference is not clearly indicated. RESULTS AND DISCUSSION The effects of the two experimiiental lniotics wvere comipared wvith the control on peripheral anterior synechia, pupillary size, and postoperative status of the vitreous face. Miotics in Cataract Surgery 239 The data shown in Table 2 indicate that miotics used intracamerally, after extraction of the lens, are of value in preventing peripheral anterior synechia in round pupil cataract surgery. The incidence of peripheral anterior synechia in the BSS group (35 per cent) is significantly higher than that for the carbachol (11 per cent) and miochol (15 per cent) groups. Although the results for carbachol were somewhat better than for miochol, there was no statistically significant difference between the two groups in this respect. TABLE 2. PERIPHERAL ANTERIOR SYNECHIA 7 WEEKS POST SURGERY Carbachol Miochol BSS control 0.01 per cent 1.0 per cent N = 43 N = 44 N = 34 35 11 15 In the examination of the preextraction pupil sizes, no significant differences were found among the three treatment groups, as shown in Table 3. Differences here would suggest the possibility of bias in the assignment of patients to the treatment groups. Apparently the groups showed significant decreases (p = .01) in pupillary size between the immediate postextraction and two-minute times. The difference was not significant between the carbachol and miochol groups with regard to the magnitude or pattern of the decrease; however, the decrease for these two groups was significantly greater (p < .01) than the smaller (but still significant) decrease observed for the BSS group. At the 15- hour time the pupillary size showed no significant difference from the five-minute time in the carbachol and BSS groups. On the other hand, the miochol group exhibited a marked increase in pupillary size at the 15- hour time as compared to the five-minute time. At the 15-hour time, the mean pupillary size for the miochol group was not significantly different from that of the BSS group and was significantly larger (p < .01) than that of the carbachol group. The group means at the four points in time at which measures were taken are shown graphically in Figure 1. Observations of the vitreous face, shown in Table 4, indicate that overall approximately 50 per cent were not intact at the seven-week time. Although the figures suggest that carbachol might preserve the integrity of the vitreous face better than miochol, there was no statistic- ally significant difference. It is reasonable to assume that miotics would protect the vitreous face at the time of surgery, but the results in this study do not indicate any advantage in the immediate postoperative period. z R1 1-4cl - 0o > :0A o) cq cN- U2 0 U2~ w°' -U U0 - co z C9 U ON ct61 izi Om1 U)i 0 - -.rv o ,0 Miotics in Cataract Surgery 241 6 F- A--- B S S .........'t CARBACHOL * *- MIOCHOL iE 5'- A' wn N co , -\ 4 -J -I 0. *|0 te@|||l@|8,|llll,l,0@|||||||||"@ 3'- II 15 POST 2 5 15 EXTRACTION MIN. MIN. HOURS TIME FIGURE 1 Pupillary size at post extraction at 2 minutes, 5 minutes and at 15 hours after intra- camera BSS, miochol, and carbachol. TABLE 4. PERCENT OF EACH GROUP WITH VITREOUS FACE INTACT AT 4, 21, AND 48 DAYS POSTOPERATIVE Total BSS Carbachol Miochol Intact vitreous sample control 0.01 per cent 1.0 per cent face (percent) N = 121 N = 43 N = 44 N = 34 At 4 days 96 95 100 91 Also at 21 days 64 51 77 62 Also at 48 days 48 40 61 41 242 Beasley CONCLUSIONS The intracameral injection of miotics after extraction of the lens in round pupil cataract surgery reduces peripheral anterior synechia. A dilute solution of carbachol (0.01 per cent) is as effective for prompt miosis as acetylcholine (1.0 per cent), but miosis is more prolonged with car- bachol. ACKNOWLEDGMENT I wish to thank Dr S. B. Sells for his assistance in the preparation of this paper. REFERENCES 1. Schimek, R. A., The use of intraocular acetylcholine in anterior segment surgery, Ann. Inst. Barraquer, 2:687, 1961. 2. Dunnington, John H., In discussion of S. M. Truhlsen, Three versus five corneo- scleral sutures, Tr. Am. Ophth. Soc., 66:156, 1968. 3. Harley, R. D., and J. E. Mishler, Acetylcholine in cataract surgery, Brit. J. Ophth., 50:429, 1966. 4. Catford, G. V., and E. Nullis, Clinical experience in the intraocular use of ace- tylcholine, Brit. J. Ophth., 51:183, 1967. 5. Harley, R. D., and J. E. Mishler, Acetylcholine in cataract surgery, Am. J. Ophth., 57:817, 1964. 6. Barraquer, J. I., Acetylcholine as a miotic agent for use in surgery, Am. J. Ophth., 57:406, 1964. 7. Rizzuti, A. B., Acetylcholine in surgery of the lens, iris, and cornea, Am. J. Ophth., 63:484, 1967. 8. Beasley, Harold, A. Russell Borgmann, Thomas 0. McDonald, and Phillip R. Belluscio, Carbachol in cataract surgery, A.M.A. Arch. Ophth., 80:39, 1968. DISCUSSION DR S. M. TRUHLSEN. Dr Beasley has shown that acetylcholine and carbachol are effective in producing rapid miosis when injected into the anterior cham- ber following cataract extraction. In addition to the immediate effects of protecting the vitreous face and pulling the iris away from the wound, these eyes, when examined gonioscopically have significantly fewer peripheral anterior synechiae (PAS) than those in which balanced salt solution (BSS) was used as a control. In assessing the incidence of postoperative PAS, including adherence of the iris to the posterior lips of the wound, factors other than immediate postoperative miosis must be considered. The integrity of the wound during the postoperative period is most important since early shallowing or flattening of the anterior chamber secondary to wound leak may contribute to the formation of PAS.
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