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Intraocular Pressure Rise After Phacoemulsification Prophylactic

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Intraocular Pressure Rise After Phacoemulsification Prophylactic British Journal of Ophthalmology 1995; 79: 809-813 809 Intraocular pressure rise after phacoemulsification Br J Ophthalmol: first published as 10.1136/bjo.79.9.809 on 1 September 1995. Downloaded from with posterior chamber lens implantation: effect of prophylactic medication, wound closure, and surgeon's experience Thomas G Bomer, Wolf-Dietrich A Lagreze, Jens Funk Abstract pressure rises usually occur between 6 and 8 Aims-A prospective clinical trial was hours after surgery.6 carried out to evaluate the effect of Various antiglaucomatous agents have been prophylactic medication, the technique of used to prevent the intraocular pressure rise wound closure, and the surgeon's experi- after cataract extraction. Oral acetazolamide15 16 ence on the intraocular pressure rise after and topical timolol'6-19 lowered the pressure cataract extraction. rise in the early period after intracapsular and Methods-In 100 eyes, the intraocular extracapsular cataract extraction. Levobunolol pressure was measured before as well as proved to be superior to timolol 4-7 hours 2-4, 5-7, and 22-24 hours after phaco- after extracapsular cataract extraction.20 Apra- emulsification and posterior chamber lens clonidine lowered the intraocular pressure rise implantation. Each of 25 patients received after uncomplicated phacoemulsification21 and either 1% topical apraclonidine, 0.5%/o extracapsular cataract extraction22 23 when topical levobunolol, 500 mg oral acetazo- given 30 minutes to 1 hour before surgery, lamide, or placebo. Forty four eyes were whereas immediate postoperative treatment operated with sclerocorneal sutureless with apraclonidine was ineffective.22 24 Miotics tunnel and 56 eyes with corneoscleral are frequently used to promote miosis and incision and suture. Sixty three operations prevent intraocular pressure rise. Intra- were performed by experienced surgeons cameral25-28 and topical24 carbachol reduced (more than 300 intraocular operations) the pressure rise for at least 24 hours. and 37 by inexperienced surgeons (less Intracameral acetylcholine28-30 and topical than 200 intraocular operations). viscous pilocarpine24 28 31 lowered the intra- Results-The pressure increase from ocular pressure rise for at least 6 hours after baseline to the maximum 5-7 hours after extracapsular cataract extraction, whereas pilo- http://bjo.bmj.com/ surgery did not differ significantly carpine solution was ineffective.24 31 (p=0.8499) for apraclonidine (9.5 mm Although phacoemulsification with posterior Hg), levobunolol (7.2 mm Hg), acetazo- chamber lens implantation is being performed lamide (7.8 mm Hg), and placebo (8.6 mm increasingly, only few reports on the preven- Hg). The increase was significantly tion of intraocular pressure rise in the early (p=0.0095) lower in eyes with corneo- postoperative period are available for this scleral tunnel (5 5 mm Hg) than in eyes technique.2' 30 We conducted a randomised, on September 28, 2021 by guest. Protected copyright. with corneoscleral suture (10.5 mm Hg) double masked, and placebo controlled study and significantly (p=00156) lower for to compare the effect of topical levobunolol, experienced (6.6 mm Hg) than for inex- topical apraclonidine, and oral acetazolamide perienced surgeons (11.2 mm Hg). in preventing intraocular pressure rise in the Conclusions-The intraocular pressure early period after phacoemulsification and rise after phacoemulsification and pos- posterior chamber lens implantation. Further- terior chamber lens implantation depends more, we compared the effect of prophylactic strongly on the technique of wound medication on the intraocular pressure rise closure and the surgeon's experience. with the effect of the surgeon's experience and Compared with these two factors, the the operation technique. effect of prophylactic medication can be neglected. (Br_J Ophthalmol 1995; 79: 809-813) Patients and methods A total of 100 patients scheduled for cataract University Eye extraction with phacoemulsification and pos- Hospital, Freiburg, Intraocular pressure increase frequently occurs terior chamber lens implantation were ran- Germany in the early period after cataract extraction.1-5 domly assigned to one of the following groups: T G Bomer Pressure rises to high levels are often painful and (1) two drops 1% apraclonidine hydrochloride W-D A Lagreze, J Funk have been associated with complications such as 1 hour before and one capsule placebo anterior ischaemic optic neuropathy, comeal immediately after surgery, (2) two drops 0-5% Correspondence to: Thomas G Bomer, MD, oedema, and deterioration of visual field in levobunolol 1 hour before and one capsule University Eye Hospital, glaucomatous eyes.69 The increase in intra- placebo immediately after surgery, (3) two Killianstrasse 5, 79106 Freiburg, Germany. ocular pressure is more pronounced with the drops placebo (artificial tears) 1 hour before Accepted for publication use of viscoelastic substances, especially when and one sustained release capsule of 500 mg 24 April 1995 left in the anterior chamber."1014 Maximum acetazolamide immediately after surgery, or 810 Bomer, Lagrese, Funk (4) two drops of artificial tears 1 hour before ointment was given at the end of the procedure and one capsule placebo immediately after to promote miosis. Br J Ophthalmol: first published as 10.1136/bjo.79.9.809 on 1 September 1995. Downloaded from surgery. A sample size of 22 eyes in each treat- Intraocular pressure was measured by two ment group was calculated to be necessary to investigators (TB and WL), who knew the detect a real difference in mean intraocular patient's randomisation number but were not pressure rise of 5 mm Hg between two treat- informed about the medication and the ment groups with a statistical power of 90/o, surgeon. All measurements were performed by assuming a standard deviation of 5 mm Hg for applanation tonometry, using the same the mean increase in intraocular pressure and Goldmann applanation tonometer for a par- accepting a type I error ot<0 05 to be significant ticular patient at each time interval. To correct in a two tailed t text. A sample size of 25 was for astigmatism, the mean of the measure- chosen for each treatment group. ments taken with tonometer prism aligned There were 72 women and 28 men in the horizontally and vertically was calculated. study. The average age was 73 0 (SD 11-0) Measurements were taken in miosis and years. Exclusion criteria were history of mydriasis the day before surgery, as well as glaucoma, uveitis, previous intraocular surgery, 2-4, 5-7, and 22-24 hours after surgery. The comeal disorders complicating applanation mean of the preoperative measurements in tonometry, and contraindications against the miosis and mydriasis was taken for baseline medication used in the study. The study was value. After each measurement, possible approved by the independent human study wound fistulation was checked using fluor- committee of the University Eye Hospital, escein. Four patients with visible fistulae were Freiburg. Informed consent was obtained from excluded. A further 18 patients were excluded all patients. owing to violation of the study protocol (12 All patients underwent uncomplicated patients) or posterior capsule rupture with vit- phacoemulsification with implantation of a reous prolapse (six patients). One patient three piece (diameter of optics 6-5 mm) treated with apraclonidine received 500 mg posterior chamber lens. Operations were per- intravenous acetacolamide because ofa painful formed by seven different surgeons. Five pressure elevation of up to 48 mm Hg at the 'experienced' surgeons had performed intra- 5-7 hour measurement point and was also ocular surgery for 2 to 8 years and had done excluded. Overall, 123 patients were recruited, 300 to 2000 intraocular operations. Two of whom 23 were excluded. In case of 'beginners' had performed intraocular surgery exclusion, one of us (JF) was informed about for 2 and 4 months and had done fewer than the patient's randomisation number to extend 200 intraocular operations at the beginning of the randomisation list by the medication the study. A total of 63 eyes were operated by for which the excluded patient had been experienced and 37 eyes by inexperienced scheduled. surgeons. On the preoperative day, one drop of Mean intraocular pressures were analysed gentamicin 0-5%, one drop of indomethacin by the paired Wilcoxon signed rank test, a non- 10%, and one drop of scopolamine 0-25% parametric version of the paired Student's t http://bjo.bmj.com/ were instilled in three sets at 60 minute test. Mean intraocular pressure rises were intervals. On the operation day, one drop of compared by Scheffes analysis of variance, gentamicin 0-5%, one drop of indomethacin which is very robust to violation of the assump- 10%, one drop of scopolamine 0-25%, and one tion of equal variances. Differences of the drop of phenylephrine hydrochloride 10% frequency in pressure rises were analysed by were instilled in four sets at 30 minute Fisher's exact test for 2 x2 contingency tables. intervals, beginning 2 hours before surgery. on September 28, 2021 by guest. Protected copyright. Each patient received a retrobulbar block (4 0 (SD 1-0) ml) with 2% mepivacaine hydro- Results chloride. Constant pressure of 40 mm Hg was The four treatment groups did not differ applied for 10 minutes, using a Geuder significantly with regard to the patient's age balloon. A 7 mm wide comeoscleral lamellar and sex, the baseline IOP, the time needed for incision (56 eyes) or a 7 mm wide and 3-5 mm phacoemulsification,
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