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Aspirin, Bleeding, and Ophthalmic Surgery
AMERICAN JOURNAL OF OPHTHALMOLOGY FRANK
W.
NEWELL,
Editor-in-Chief
160 East Grand Ave.( Chicago, Illinois 60611
Editor-in-Chief Emeritus 110 East Sheridan Road, Lake Bluff, Illinois 60044 DERRICK VAIL,
E D I T O R I A L BOARD Bernard Becker, St. Louis Frederick C. Blodi, Iowa City Benjamin F. Boyd, Panama Thomas Chalkley, Chicago Sir Stewart Duke-Elder, London DuPont Guerry III, Richmond Michael J. Hogan, San Francisco Robert W. Hollenhorst, Rochester Herbert E. Kaufman, Gainesville Arthur H. Keeney, Philadelphia Bertha A. Klien, Chicago Alex E. Krill, Chicago
Carl Kupfer, Bethesda James E. Lebensohn, Chicago Irving H. Leopold, New York A. Edward Maumenee, Baltimore Edward W. D. Norton, Miami Albert M. Potts, Chicago Algernon B. Reese, New York Marvin L. Sears, New Haven David Shoch, Chicago George K. Smelser, New York Phillips Thygeson, San Francùco Gunter K. von Noorden, Baltimore
Published monthly by the Ophthalmic Publishing Company Directors:
DERRICK VAIL. President; ALGERNON B. REESE, Vice-President; FRANK W. NEWELL, Secretary and Treasurer; A. EDWARD MAUMENEE, MICHAEL J. HOGAN, EDWARD W. D. NORTON
ASPIRIN, BLEEDING, AND O P H T H A L M I C SURGERY Reverend Edm. Stone of Chipping-Norton, Oxfordshire, tells in the Philosophical Transactions of April 25, 1763, that he tasted the bark of the English willow tree (Salix alba vulgaris) in 1757 and that he was surprised at its extraordinary bitterness which immediately raised in his mind the suspicion of its having the properties of the Peruvian bark. He could not find that it had any place in pharmacy. He then collected and dried a pound of the bark, reduced it to a powder, and later dosed himself with about 20 grains every four hours and although he
felt better, his ague continued. In a few days he increased the dose to 2 scr. and his ague was removed. With several other patients he found a dose of a dram every four hours effective although in some agues it was nec essary to add the Peruvian bark. Thus Rev erend Stone discovered the antipyretic ac tion of the salicylates which today constitute one of the most important classes antipyretic and analgesic drugs. The toxic effects of salicylates are well known : nausea and vomiting caused by cen tral stimulation with high dosage and gastric irritation with low dosage. There may be dis turbances in the acid base balance, with ei-
559
560
AMERICAN JOURNAL OF OPHTHALMOLOGY
ther alkalosis or acidosis. Mainly, however, physicians are most familiar with the effects arising from salicylate intoxication or idiosyncracy: headache, tinnitus, deafness, men tal confusion, and skin rash. To judge from radio commercials, salicylates and particularly aspirin, must be one of the most widely used drugs in America. Fre quently, one's patients do not regard it as medication and they must he queried specifi cally as to whether or not they have used it. In 1969, investigators showed that a single normal therapeutic dose of aspirin prolonged bleeding time and interfered with platelet ag gregation for five days or more. Earlier, Link showed that extremely large doses pro longed prothrombin time. Mielke and Britten of the New England Medical Center Hospi tals recently studied 50 selected blood do nors, 21 of whom had ingested aspirin within one week of donation. Nineteen had abnormal bleeding times and all had abnor mal aggregation of platelets. Of the remain ing 29 donors who had not taken aspirin within one week, three had abnormal bleed ing times and two had abnormal platelet ag gregation. A recent book, Aspirin, Platelets, and Stroke: Background for a Clinical Trial, presents nearly verbatim the report of a June, 1970, conference concerning the feasi bility of treating thromboembolic cerebrovascular disease with aspirin. The book pro vides a description of the pharmacology of aspirin and the proposed clinical trial, which presents innumerable problems. Addition ally, aspirin has been used to treat amaurosis fugax caused by occlusive disease of the in ternal carotid artery. Many ophthalmic surgeons often pre scribe aspirin with or without codeine for analgesia following ophthalmic surgery. Its excretion in the urine may be delayed by the administration of acetazolamide which com petes for the transport system in the proxi mal tubule. This provides a welcome prolon gation of analgesia in the postoperative pa tient and is possibly good prophylaxis
SEPTEMBER, 1972
against pulmonary infarction, but it also cre ates an excellent system for prolonging bleeding time. Although hyphema occurs relatively in frequently following intraocular surgery, in light of the effects of aspirin in prolonging bleeding time it would seem prudent to limit or even forego its use in patients who have had intraocular surgery. Additionally, it seems wise to be assured that patients have not used aspirin the week preceding surgery. Conversely, the drug may prove useful in the management of retinal vein closure, in thromboembolic disease of the cerebrovascular system, and in similar afflictions, but many controlled studies are required before its usefulness in these areas is confirmed. Frank W. Newell REFERENCE
Mielke, C. H., Jr., and Britten, A. F. H. : Aspirin: A new nightmare for blood bankers. New Eng. J. Med. 286:268, 1972. Benjamin, S. P., and Hoffman, G. G: "Aspirinated" platelets are hemostatic. New Eng. J. Med. 286:784, 1972.
CORRESPONDENCE THERAPY I N GLAUCOMATOUS PATIENTS WITH ACUTE PRESSURE INCREASE
Editor, American Journal of Ophthalmology : Since 1967, I have treated six patients with an acute increase of intraocular pres sure in angle-closure glaucoma with systemic and topical dexamethasone. An initial dose of 8 mg of intramuscular dexamethasone was given and if the tension was not de creased in 30 minutes, an additional 4 to 8 mg was given. The first four patients (Table 1 ) received intramuscular acetazolamide, but the final two did not. In addition, to dexa methasone and acetazolamide, the patients received 2% pilocarpine and dexamethasone ophthalmic solutions topically every five minutes for three to five applications. I believe that corticosteroids may reduce
W.
NEWELL,
Editor-in-Chief
160 East Grand Ave.( Chicago, Illinois 60611
Editor-in-Chief Emeritus 110 East Sheridan Road, Lake Bluff, Illinois 60044 DERRICK VAIL,
E D I T O R I A L BOARD Bernard Becker, St. Louis Frederick C. Blodi, Iowa City Benjamin F. Boyd, Panama Thomas Chalkley, Chicago Sir Stewart Duke-Elder, London DuPont Guerry III, Richmond Michael J. Hogan, San Francisco Robert W. Hollenhorst, Rochester Herbert E. Kaufman, Gainesville Arthur H. Keeney, Philadelphia Bertha A. Klien, Chicago Alex E. Krill, Chicago
Carl Kupfer, Bethesda James E. Lebensohn, Chicago Irving H. Leopold, New York A. Edward Maumenee, Baltimore Edward W. D. Norton, Miami Albert M. Potts, Chicago Algernon B. Reese, New York Marvin L. Sears, New Haven David Shoch, Chicago George K. Smelser, New York Phillips Thygeson, San Francùco Gunter K. von Noorden, Baltimore
Published monthly by the Ophthalmic Publishing Company Directors:
DERRICK VAIL. President; ALGERNON B. REESE, Vice-President; FRANK W. NEWELL, Secretary and Treasurer; A. EDWARD MAUMENEE, MICHAEL J. HOGAN, EDWARD W. D. NORTON
ASPIRIN, BLEEDING, AND O P H T H A L M I C SURGERY Reverend Edm. Stone of Chipping-Norton, Oxfordshire, tells in the Philosophical Transactions of April 25, 1763, that he tasted the bark of the English willow tree (Salix alba vulgaris) in 1757 and that he was surprised at its extraordinary bitterness which immediately raised in his mind the suspicion of its having the properties of the Peruvian bark. He could not find that it had any place in pharmacy. He then collected and dried a pound of the bark, reduced it to a powder, and later dosed himself with about 20 grains every four hours and although he
felt better, his ague continued. In a few days he increased the dose to 2 scr. and his ague was removed. With several other patients he found a dose of a dram every four hours effective although in some agues it was nec essary to add the Peruvian bark. Thus Rev erend Stone discovered the antipyretic ac tion of the salicylates which today constitute one of the most important classes antipyretic and analgesic drugs. The toxic effects of salicylates are well known : nausea and vomiting caused by cen tral stimulation with high dosage and gastric irritation with low dosage. There may be dis turbances in the acid base balance, with ei-
559
560
AMERICAN JOURNAL OF OPHTHALMOLOGY
ther alkalosis or acidosis. Mainly, however, physicians are most familiar with the effects arising from salicylate intoxication or idiosyncracy: headache, tinnitus, deafness, men tal confusion, and skin rash. To judge from radio commercials, salicylates and particularly aspirin, must be one of the most widely used drugs in America. Fre quently, one's patients do not regard it as medication and they must he queried specifi cally as to whether or not they have used it. In 1969, investigators showed that a single normal therapeutic dose of aspirin prolonged bleeding time and interfered with platelet ag gregation for five days or more. Earlier, Link showed that extremely large doses pro longed prothrombin time. Mielke and Britten of the New England Medical Center Hospi tals recently studied 50 selected blood do nors, 21 of whom had ingested aspirin within one week of donation. Nineteen had abnormal bleeding times and all had abnor mal aggregation of platelets. Of the remain ing 29 donors who had not taken aspirin within one week, three had abnormal bleed ing times and two had abnormal platelet ag gregation. A recent book, Aspirin, Platelets, and Stroke: Background for a Clinical Trial, presents nearly verbatim the report of a June, 1970, conference concerning the feasi bility of treating thromboembolic cerebrovascular disease with aspirin. The book pro vides a description of the pharmacology of aspirin and the proposed clinical trial, which presents innumerable problems. Addition ally, aspirin has been used to treat amaurosis fugax caused by occlusive disease of the in ternal carotid artery. Many ophthalmic surgeons often pre scribe aspirin with or without codeine for analgesia following ophthalmic surgery. Its excretion in the urine may be delayed by the administration of acetazolamide which com petes for the transport system in the proxi mal tubule. This provides a welcome prolon gation of analgesia in the postoperative pa tient and is possibly good prophylaxis
SEPTEMBER, 1972
against pulmonary infarction, but it also cre ates an excellent system for prolonging bleeding time. Although hyphema occurs relatively in frequently following intraocular surgery, in light of the effects of aspirin in prolonging bleeding time it would seem prudent to limit or even forego its use in patients who have had intraocular surgery. Additionally, it seems wise to be assured that patients have not used aspirin the week preceding surgery. Conversely, the drug may prove useful in the management of retinal vein closure, in thromboembolic disease of the cerebrovascular system, and in similar afflictions, but many controlled studies are required before its usefulness in these areas is confirmed. Frank W. Newell REFERENCE
Mielke, C. H., Jr., and Britten, A. F. H. : Aspirin: A new nightmare for blood bankers. New Eng. J. Med. 286:268, 1972. Benjamin, S. P., and Hoffman, G. G: "Aspirinated" platelets are hemostatic. New Eng. J. Med. 286:784, 1972.
CORRESPONDENCE THERAPY I N GLAUCOMATOUS PATIENTS WITH ACUTE PRESSURE INCREASE
Editor, American Journal of Ophthalmology : Since 1967, I have treated six patients with an acute increase of intraocular pres sure in angle-closure glaucoma with systemic and topical dexamethasone. An initial dose of 8 mg of intramuscular dexamethasone was given and if the tension was not de creased in 30 minutes, an additional 4 to 8 mg was given. The first four patients (Table 1 ) received intramuscular acetazolamide, but the final two did not. In addition, to dexa methasone and acetazolamide, the patients received 2% pilocarpine and dexamethasone ophthalmic solutions topically every five minutes for three to five applications. I believe that corticosteroids may reduce