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Cardiovascular hazard of intracameral phenylephrine
2021
CORRESPONDENCE
Figure 2. Conjoined IOLs in Case 1 (A, B) and Case 2 (C, D). Note the adhesion at the haptics.
to perform IOL exchange early after the initial surgery when there is little fibrosis of the lens capsule. The IOL may have a defect from the manufacturing process or from implantation.4,5 Therefore, early identification of IOL structural defects is crucial to prevent functional visual loss later. Before beginning any surgical steps, and as part of the surgical time-out, the surgical team checks the patient's name, side, intended IOL power, and the IOL label.1 However, during loading, the surgeon does not routinely inspect the IOL. Sometimes it is the assistant or nurse who loads the IOL. In Case 1, the defect was noted postoperatively as it was extracapsular extraction and the IOL was implanted without the injector. Our cases indicate that the IOL should also be inspected before implantation in the bag (or loading into the injector) or if the surgeon is unable to inject the IOL on repeated attempts. Intraocular lens manufacturers have been notified about this unusual cause of a refractive surprise to enhance their quality monitoring of IOLs. REFERENCES 1. Simon JW, Ngo Y, Khan S, Strogatz D. Surgical confusions in ophthalmology. Arch Ophthalmol 2007; 125:1515–1522. Available at: http://archopht.jamanetwork.com/data/Journals/OPHT H/9994/ecs70044_1515_1522.pdf. Accessed July 24, 2015 2. Findl O, Menapace R. Piggyback intraocular lenses [letter]. J Cataract Refract Surg 2000; 26:308–309; reply by JK Shugar, 309 3. Alkhateeb M, Mashaqbeh M, Magableh S, Hadad R, Nseer Q, Alshboul A. Early prenatal diagnosis of thoracopagus twins by ultrasound. Acta Inform Med 2015; 23:60–62. Available at: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC4384844/pdf/AIM-23-60. pdf. Accessed July 24, 2015 4. Pfister DR. Stress fractures after folding an acrylic intraocular lens. Am J Ophthalmol 1996; 121:572–574 5. Balasubramanya R, Rani A, Dada T. Forceps-induced cracking of a single-piece acrylic foldable intraocular lens. Ophthalmic Surg Lasers Imaging 2003; 34:306–307
Cardiovascular hazard of intracameral phenylephrine Fatemeh Shams, BSc, MSc, MB BS, Amir A. Jafari, MB BS, David Mansfield, MA, PhD, FRCS, FRCOphth In 2007, Gurbaxani and Packard1 commended the use of intracameral phenylephrine (0.25 mL of minims phenylephrine hydrochloride 2.5% mixed with 1 mL of balanced salt solution) to boost pupil dilation and reduce the technical difficulties associated with intraoperative floppy-iris syndrome (IFIS). The recent occurrence of ventricular fibrillation in 1 of our patients within a minute of this infusion prompted us to review the safety of phenylephrine. Proof that phenylephrine is responsible for adverse reactions is not simple. Ventricular fibrillation occurs spontaneously, and other drugs confound the issue. The mechanism of action of the drug, the timing of cardiovascular events, and the dose dependence of the frequency of reactions are reasons to consider phenylephrine as the sole cause of disastrous complications.
J CATARACT REFRACT SURG - VOL 41, SEPTEMBER 2015
2022
CORRESPONDENCE
Serious adverse reactions attributed to phenylephrine have been reported over the past 6 decades. Fraunfelder and Scafidi2 reviewed the complications after topical phenylephrine. Fifteen of 32 entailed cardiac arrest, and 11 of those were fatal. Others have pointed out the occurrence of severe pulmonary hypertension,3 systemic hypertension,4 and rupture of intracranial aneurysms.5 Perhaps only a small subset of patients is at risk. Preexisting cardiac arrhythmia may predispose to induction of ventricular fibrillation. The patient’s cardiovascular status and history must be known before deciding to use phenylephrine in or on the eye. Cataract surgeons around the world use various concentrations of intracameral phenylephrine, some much lower concentrations than the concentration we used in our patient. This may be safer relative to the total dose of phenylephrine exposure; however, the efficacy of the various concentrations is not clear. In 2003, Lundberg and Behndig6 compared pupil dilation using intracameral phenylephrine (15 mg/mL) alone with dilation using topical mydriatics (cyclopentolate 1.0% and phenylephrine 10.0%). They found that the intracameral mydriatic alone produced a significant pupil dilation of 6.7 mm G 1.0 (SD), which was sustained throughout the procedure. However, this dilation was statistically less than the dilation with topical mydriatics, which was 7.7 G 1.0 mm but had shorter sustainability. In 2010, the same group7 showed that phenylephrine given intracamerally resulted in the same mydriatic effect in concentrations between 0.15 mg/mL and 5.00 mg/mL but had a significantly greater effect in higher concentrations of 15 mg/mL and 30 mg/mL. Topical mydriatics have lower bioavailability8 and higher systemic absorption.9 In patients with cardiovascular risk factors, it may be plausible to use only intracameral phenylephrine for dilation or topical cyclopentolate 1.0% and intracameral phenylephrine, reducing the systemic absorption and side effects of the drug. Whether this would be effective in reducing the risk for IFIS in patients on a antagonists is unknown as no studies have performed a direct comparison. Prudence dictates that one consider the total dose of phenylephrine used, preferring 2.5% drops to 10.0%. Bilateral application doubles the dose. Surgeons might prefer to use iris hooks or a Malyugin ring rather than extra phenylephrine. We recommend cardiovascular monitoring of patients with risk factors and the ready availability of anesthetists experienced in cardiopulmonary resuscitation. Intermittent verbal communication with the patient and use of topical anesthesia (enabling the surgeon to see whether the patient loses voluntary fixation) can
aid immediate recognition of the onset of ventricular fibrillation. This caution applies to pupil dilation for both cataract surgery and photography. REFERENCES 1. Gurbaxani A, Packard R. Intracameral phenylephrine to prevent floppy iris syndrome during cataract surgery in patients on tamsulosin. Eye 2007; 21:331–332. Available at: http://www.nature. com/eye/journal/v21/n3/pdf/6702172a.pdf. Accessed July 24, 2015 2. Fraunfelder FT, Scafidi AF. Possible adverse effects from topical ocular 10% phenylephrine. Am J Ophthalmol 1978; 85:447–453 3. Baldwin FJ, Morley AP. Intraoperative pulmonary oedema in a child following systemic absorption of phenylephrine eyedrops. Br J Anaesth 2002; 88:440–442. Available at: http://bja.oxford journals.org/content/88/3/440.full.pdf. Accessed July 24, 2015 4. Lai YK. Adverse effect of intraoperative phenylephrine 10%: case report. Br J Ophthalmol 1989; 73:468–469. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1041770/pdf/brjo pthal00598-0070.pdf. Accessed July 24, 2015 5. Samantary S, Thomas A. Systemic effects of topical phenylephrine. Indian J Ophthalmol 1975; 23:16–17. Available at: http:// www.ijo.in/text.asp?1975/23/1/16/31338. Accessed July 24, 2015 6. Lundberg B, Behndig A. Intracameral mydriatics in phacoemulsification cataract surgery. J Cataract Refract Surg 2003; 29:2366–2371 7. Behndig A, Lundberg B. Mydriatic response to different concentrations of intracameral phenylephrine in humans. J Cataract Refract Surg 2010; 36:1682–1686 8. Doane MG, Jensen AD, Dohlman CH. Penetration routes of topically applied eye medications. Am J Ophthalmol 1978; 85:383–386 9. Haaga M, Kaila T, Salminen L, Ylitalo P. Systemic and ocular absorption and antagonist activity of topically applied cyclopentolate in man. Pharmacol Toxicol 1998; 82:19–22
Use of a single peripheral triangular mark to ensure correct graft orientation in Descemet membrane endothelial keratoplasty Maninder Bhogal, MB BS, FRCOphth, Vincenzo Maurino, MD, Bruce D. Allan, MD, FRCS, FRCOphth Online Video Descemet membrane endothelial keratoplasty (DMEK) is the latest iteration of endothelial keratoplasty.1 Correct anatomical orientation is essential for the success of all endothelial surgeries. Since DMEK tissue scrolls, the graft can rotate during injection or unfolding and no device currently exists to ensure that correct orientation is maintained during insertion and manipulation. Tissue inversion is a significant yet avoidable cause of primary graft failure and total graft dislocation, which are significantly
J CATARACT REFRACT SURG - VOL 41, SEPTEMBER 2015
CORRESPONDENCE
Figure 2. Conjoined IOLs in Case 1 (A, B) and Case 2 (C, D). Note the adhesion at the haptics.
to perform IOL exchange early after the initial surgery when there is little fibrosis of the lens capsule. The IOL may have a defect from the manufacturing process or from implantation.4,5 Therefore, early identification of IOL structural defects is crucial to prevent functional visual loss later. Before beginning any surgical steps, and as part of the surgical time-out, the surgical team checks the patient's name, side, intended IOL power, and the IOL label.1 However, during loading, the surgeon does not routinely inspect the IOL. Sometimes it is the assistant or nurse who loads the IOL. In Case 1, the defect was noted postoperatively as it was extracapsular extraction and the IOL was implanted without the injector. Our cases indicate that the IOL should also be inspected before implantation in the bag (or loading into the injector) or if the surgeon is unable to inject the IOL on repeated attempts. Intraocular lens manufacturers have been notified about this unusual cause of a refractive surprise to enhance their quality monitoring of IOLs. REFERENCES 1. Simon JW, Ngo Y, Khan S, Strogatz D. Surgical confusions in ophthalmology. Arch Ophthalmol 2007; 125:1515–1522. Available at: http://archopht.jamanetwork.com/data/Journals/OPHT H/9994/ecs70044_1515_1522.pdf. Accessed July 24, 2015 2. Findl O, Menapace R. Piggyback intraocular lenses [letter]. J Cataract Refract Surg 2000; 26:308–309; reply by JK Shugar, 309 3. Alkhateeb M, Mashaqbeh M, Magableh S, Hadad R, Nseer Q, Alshboul A. Early prenatal diagnosis of thoracopagus twins by ultrasound. Acta Inform Med 2015; 23:60–62. Available at: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC4384844/pdf/AIM-23-60. pdf. Accessed July 24, 2015 4. Pfister DR. Stress fractures after folding an acrylic intraocular lens. Am J Ophthalmol 1996; 121:572–574 5. Balasubramanya R, Rani A, Dada T. Forceps-induced cracking of a single-piece acrylic foldable intraocular lens. Ophthalmic Surg Lasers Imaging 2003; 34:306–307
Cardiovascular hazard of intracameral phenylephrine Fatemeh Shams, BSc, MSc, MB BS, Amir A. Jafari, MB BS, David Mansfield, MA, PhD, FRCS, FRCOphth In 2007, Gurbaxani and Packard1 commended the use of intracameral phenylephrine (0.25 mL of minims phenylephrine hydrochloride 2.5% mixed with 1 mL of balanced salt solution) to boost pupil dilation and reduce the technical difficulties associated with intraoperative floppy-iris syndrome (IFIS). The recent occurrence of ventricular fibrillation in 1 of our patients within a minute of this infusion prompted us to review the safety of phenylephrine. Proof that phenylephrine is responsible for adverse reactions is not simple. Ventricular fibrillation occurs spontaneously, and other drugs confound the issue. The mechanism of action of the drug, the timing of cardiovascular events, and the dose dependence of the frequency of reactions are reasons to consider phenylephrine as the sole cause of disastrous complications.
J CATARACT REFRACT SURG - VOL 41, SEPTEMBER 2015
2022
CORRESPONDENCE
Serious adverse reactions attributed to phenylephrine have been reported over the past 6 decades. Fraunfelder and Scafidi2 reviewed the complications after topical phenylephrine. Fifteen of 32 entailed cardiac arrest, and 11 of those were fatal. Others have pointed out the occurrence of severe pulmonary hypertension,3 systemic hypertension,4 and rupture of intracranial aneurysms.5 Perhaps only a small subset of patients is at risk. Preexisting cardiac arrhythmia may predispose to induction of ventricular fibrillation. The patient’s cardiovascular status and history must be known before deciding to use phenylephrine in or on the eye. Cataract surgeons around the world use various concentrations of intracameral phenylephrine, some much lower concentrations than the concentration we used in our patient. This may be safer relative to the total dose of phenylephrine exposure; however, the efficacy of the various concentrations is not clear. In 2003, Lundberg and Behndig6 compared pupil dilation using intracameral phenylephrine (15 mg/mL) alone with dilation using topical mydriatics (cyclopentolate 1.0% and phenylephrine 10.0%). They found that the intracameral mydriatic alone produced a significant pupil dilation of 6.7 mm G 1.0 (SD), which was sustained throughout the procedure. However, this dilation was statistically less than the dilation with topical mydriatics, which was 7.7 G 1.0 mm but had shorter sustainability. In 2010, the same group7 showed that phenylephrine given intracamerally resulted in the same mydriatic effect in concentrations between 0.15 mg/mL and 5.00 mg/mL but had a significantly greater effect in higher concentrations of 15 mg/mL and 30 mg/mL. Topical mydriatics have lower bioavailability8 and higher systemic absorption.9 In patients with cardiovascular risk factors, it may be plausible to use only intracameral phenylephrine for dilation or topical cyclopentolate 1.0% and intracameral phenylephrine, reducing the systemic absorption and side effects of the drug. Whether this would be effective in reducing the risk for IFIS in patients on a antagonists is unknown as no studies have performed a direct comparison. Prudence dictates that one consider the total dose of phenylephrine used, preferring 2.5% drops to 10.0%. Bilateral application doubles the dose. Surgeons might prefer to use iris hooks or a Malyugin ring rather than extra phenylephrine. We recommend cardiovascular monitoring of patients with risk factors and the ready availability of anesthetists experienced in cardiopulmonary resuscitation. Intermittent verbal communication with the patient and use of topical anesthesia (enabling the surgeon to see whether the patient loses voluntary fixation) can
aid immediate recognition of the onset of ventricular fibrillation. This caution applies to pupil dilation for both cataract surgery and photography. REFERENCES 1. Gurbaxani A, Packard R. Intracameral phenylephrine to prevent floppy iris syndrome during cataract surgery in patients on tamsulosin. Eye 2007; 21:331–332. Available at: http://www.nature. com/eye/journal/v21/n3/pdf/6702172a.pdf. Accessed July 24, 2015 2. Fraunfelder FT, Scafidi AF. Possible adverse effects from topical ocular 10% phenylephrine. Am J Ophthalmol 1978; 85:447–453 3. Baldwin FJ, Morley AP. Intraoperative pulmonary oedema in a child following systemic absorption of phenylephrine eyedrops. Br J Anaesth 2002; 88:440–442. Available at: http://bja.oxford journals.org/content/88/3/440.full.pdf. Accessed July 24, 2015 4. Lai YK. Adverse effect of intraoperative phenylephrine 10%: case report. Br J Ophthalmol 1989; 73:468–469. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1041770/pdf/brjo pthal00598-0070.pdf. Accessed July 24, 2015 5. Samantary S, Thomas A. Systemic effects of topical phenylephrine. Indian J Ophthalmol 1975; 23:16–17. Available at: http:// www.ijo.in/text.asp?1975/23/1/16/31338. Accessed July 24, 2015 6. Lundberg B, Behndig A. Intracameral mydriatics in phacoemulsification cataract surgery. J Cataract Refract Surg 2003; 29:2366–2371 7. Behndig A, Lundberg B. Mydriatic response to different concentrations of intracameral phenylephrine in humans. J Cataract Refract Surg 2010; 36:1682–1686 8. Doane MG, Jensen AD, Dohlman CH. Penetration routes of topically applied eye medications. Am J Ophthalmol 1978; 85:383–386 9. Haaga M, Kaila T, Salminen L, Ylitalo P. Systemic and ocular absorption and antagonist activity of topically applied cyclopentolate in man. Pharmacol Toxicol 1998; 82:19–22
Use of a single peripheral triangular mark to ensure correct graft orientation in Descemet membrane endothelial keratoplasty Maninder Bhogal, MB BS, FRCOphth, Vincenzo Maurino, MD, Bruce D. Allan, MD, FRCS, FRCOphth Online Video Descemet membrane endothelial keratoplasty (DMEK) is the latest iteration of endothelial keratoplasty.1 Correct anatomical orientation is essential for the success of all endothelial surgeries. Since DMEK tissue scrolls, the graft can rotate during injection or unfolding and no device currently exists to ensure that correct orientation is maintained during insertion and manipulation. Tissue inversion is a significant yet avoidable cause of primary graft failure and total graft dislocation, which are significantly
J CATARACT REFRACT SURG - VOL 41, SEPTEMBER 2015