- Email: [email protected]
Cataract surgery without preoperative eyedrops
Cataract surgery without preoperative eyedrops Robert J. Cionni, MD, Marcı´lio G. Barros, MD, Adam H. Kaufman, MD, Robert H. Osher, MD We present a technique that uses intracameral lidocaine to induce pupil dilation without using preoperative mydriatic eyedrops. After 1 or 2 drops of topical lidocaine hydrochloride 1% (Xylocaine威-MPF 1%) are applied to the ocular surface, a 1.0 mm side-port incision is created through which Xylocaine-MPF 1% is injected into the anterior chamber. The lidocaine paralyzes the pupil sphincter, and adequate mydriasis occurs within 90 seconds. Epinephrine (0.3 cc of 1:1000) is added to the irrigation fluid comprising balanced salt solution (BSS威), and standard phacoemulsification with intraocular lens implantation is performed. Pupil dilation is maintained or increased during the procedure. Postoperatively, the pupil returns more quickly to normal size and reaction. Using lidocaine for mydriasis instead of standard dilating drops eliminates the cardiac risk of topical sympathetic agents, decreases the time patients wait in the holding area before surgery, reduces the risk of superficial punctate keratopathy, and provides faster recovery of normal pupil function. J Cataract Refract Surg 2003; 29:2281–2283 2003 ASCRS and ESCRS
P
reoperative mydriasis is normally obtained using combinations of 3 drug types: anticholinergic agents such as tropicamide 1%, cyclopentolate 1%, homatropine 5%, or scopolamine 0.25%; sympathetic agonists such as phenylephrine 2.5% or 10%; and topical nonsteroidal antiinflammatory drops such as indomethacin 1%, flurbiprofen 0.03%, or suprofen 1%. The eyedrops are typically started 1 hour before the surgical procedure.1 We describe a surgical technique using intracameral lidocaine hydrochloride 1% (Xylocaine威-MPF 1%) to induce mydriasis, avoiding all preoperative dilating eyedrops. Accepted for publication August 27, 2003. From the Cincinnati Eye Institute (Cionni, Barros, Kaufman, Osher) and the Department of Ophthalmology, University of Cincinnati College of Medicine (Cionni, Kaufman, Osher), Cincinnati, Ohio, USA, and Hospital do Olho de Rio Preto (Barros), Sa˜o Jose´ do Rio Preto, Sa˜o Paulo, Brazil. Dr. Kaufman has a Career Development Award from Research to Prevent Blindness, New York, New York, USA. None of the authors has a financial or proprietary interest in any material or method mentioned. Correspondence to Robert J. Cionni MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, Ohio 45242, USA. 2003 ASCRS and ESCRS Published by Elsevier Inc.
Surgical Technique One or 2 drops of Xylocaine-MPF 1% are applied to the ocular surface several minutes before the surgical site is prepared and draped. A side-port incision is created and 0.3 to 0.5 mL of Xylocaine-MPF 1% is injected into the anterior chamber (Figure 1). Mydriasis begins immediately, enabling the surgeon to proceed within 90 seconds (Figure 2). Instillation of viscoelastic material can further enlarge the pupil. The pupil remains dilated and may continue to enlarge if intracameral epinephrine (0.3 cc of 1:1000) is added to the infusion during routine phacoemulsification, cortical aspiration, and intraocular lens implantation.
Discussion Local anesthetic agents block conduction of nerve impulses by their direct action on voltage-gated sodium channels. Injection of intracameral lidocaine acts to some extent on all nerve fibers in the anterior chamber to provide anesthesia and akinesia of the iris. Lidocaine’s effect of iris paralysis and mydriasis was noted by Lincoff et al.2 in 1985 in a patient who received an accidental intraocular injection of lidocaine without administration of topical mydriatics. The patient recovered normal 0886-3350/03/$–see front matter doi:10.1016/j.jcrs.2003.09.009
TECHNIQUES: CIONNI
Figure 1. (Cionni) Pupil size before the introduction of Xylocaine-
Figure 2. (Cionni) Enlargement of the pupil 90 seconds after injec-
MPF 1% into the anterior chamber.
tion of Xylocaine-MPF 1%.
retinal and pupillary function within 16 hours. Pupil dilation associated with instillation of lidocaine into the anterior chamber appears to result from its blocking pupil constriction to light. Epinephrine in the infusion can further dilate the pupil by acting on the ␣ receptors of the iris radial muscles.3 Xylocaine-MPF 1% causes no additional inflammation, endothelial cell loss, or mean cell size variation, and its safety has been confirmed in patients with corneal pathologies such as guttata.4–9 It is an effective topical and intracameral anesthetic agent for cataract surgery, during which the patient seems more tolerant of the operating microscope light.10–12 In our first case, the patient’s pupil had dilated to 6.5 mm during the preoperative evaluation after 2 sets of tropicamide 1% and phenylephrine 2.5%. At the beginning of the procedure, the pupil measured 1.4 mm under the operating microscope before the XylocaineMPF 1% injection. Ninety-seven seconds after 0.5 mL of Xylocaine-MPF 1% was injected into the anterior chamber, the pupil had enlarged to 6.4 mm. At the conclusion of the procedure, the pupil measured 7.4 mm. Six hours after surgery, the pupil was normally reactive, measuring 4.5 mm in room light. Our first 12 patients achieved adequate dilation for cataract surgery. The mean pupil size before dilation was 2.4 mm (range 1.5 to 3.1 mm) and after instillation of Xylocaine-MPF 1%, 6.5 mm (range 5.2 to 7.2 mm). Xylocaine-MPF 1% appears to be effective in attaining adequate pupil dilation without using routine
dilating drops before cataract surgery. The avoidance of preoperative dilating eyedrops has several advantages. There is less likelihood of superficial punctate keratopathy, which can decrease the surgeon’s intraoperative visualization and the patient’s early postoperative vision and comfort level.13 Cardiac risks are diminished since sympathetic agents are not administered.14 Pupil size and reactivity become normal more quickly after surgery, resulting in faster visual improvement. Finally, the patient’s wait time in the holding area before surgery can be reduced, improving operating room efficiency and optimizing the patient’s experience.
2282
References 1. Hejny C, Edelhauser HF. Surgical Pharmacology: Intraocular Solutions and Drugs Used for Cataract Surgery. In: Buratto L, Werner L, Zanini M, Apple D, eds, Phacoemulsification; Principles and Techniques. Thorofare, NJ, Slack, 2003; 219–246 2. Lincoff H, Zweifach P, Brodie S, et al. Intraocular injection of lidocaine. Ophthalmology 1985; 92:1587–1591 3. Catterall W, Mackie K. Local anesthetics. In: Hardman JG, Limbird LE, eds, Goodman & Gilman’s the Pharmacological Basis of Therapeutics, 10th ed. New York, NY, McGraw-Hill, 2001; 367–384 4. Iradier MT, Fernandez C, Bohorquez P, et al. Intraocular lidocaine in phacoemulsification; an endothelium and blood-aqueous barrier permeability study. Ophthalmology 2000; 107:896–900; discussion by JP Gills, 900–901 5. Garcia A, Loureiro F, Lima˜o A, et al. Preservative-free lidocaine 1% anterior chamber irrigation as an adjunct to topical anesthesia. J Cataract Refract Surg 1998; 24:403–406
J CATARACT REFRACT SURG—VOL 29, DECEMBER 2003
TECHNIQUES: CIONNI
6. Eggeling P, Pleyer U, Hartmann C, Rieck PW. Corneal endothelial toxicity of different lidocaine concentrations. J Cataract Refract Surg 2000; 26:1403–1408 7. Kim T, Holley GP, Lee JH, et al. The effects of intraocular lidocaine on the corneal endothelium. Ophthalmology 1998; 105:125–130 8. Weller A, Pham DT, Ha¨berle H. Intracamerale Ana¨sthesie mit Lidocain bei Cornea guttata. Ophthalmologe 2002; 99:29–31 9. Martin RG, Miller JD, Cox CC III, et al. Safety and efficacy of intracameral injections of unpreserved lidocaine to reduce intraocular sensation. J Cataract Refract Surg 1998; 24:961–963 10. Gills JP, Cherchio M, Raanan MG. Unpreserved lidocaine to control discomfort during cataract surgery using
11.
12. 13.
14.
topical anesthesia. J Cataract Refract Surg 1997; 23: 545–550 Koch PS. Anterior chamber irrigation with unpreserved lidocaine 1% for anesthesia during cataract surgery. J Cataract Refract Surg 1997; 23:551–554 Brierley L. Effect of lidocaine on photophobia [letter]. J Cataract Refract Surg 1999; 25:1177 Edelhauser HF, Hine JE, Pederson H, et al. The effect of phenylephrine on the cornea. Arch Ophthalmol 1979; 97:937–947 Kumar V, Schoenwald RD, Barcellos WA, et al. Aqueous vs viscous phenylephrine. I. Systemic absorption and cardiovascular effects. Arch Ophthalmol 1986; 104: 1189–1191
J CATARACT REFRACT SURG—VOL 29, DECEMBER 2003
2283
P
reoperative mydriasis is normally obtained using combinations of 3 drug types: anticholinergic agents such as tropicamide 1%, cyclopentolate 1%, homatropine 5%, or scopolamine 0.25%; sympathetic agonists such as phenylephrine 2.5% or 10%; and topical nonsteroidal antiinflammatory drops such as indomethacin 1%, flurbiprofen 0.03%, or suprofen 1%. The eyedrops are typically started 1 hour before the surgical procedure.1 We describe a surgical technique using intracameral lidocaine hydrochloride 1% (Xylocaine威-MPF 1%) to induce mydriasis, avoiding all preoperative dilating eyedrops. Accepted for publication August 27, 2003. From the Cincinnati Eye Institute (Cionni, Barros, Kaufman, Osher) and the Department of Ophthalmology, University of Cincinnati College of Medicine (Cionni, Kaufman, Osher), Cincinnati, Ohio, USA, and Hospital do Olho de Rio Preto (Barros), Sa˜o Jose´ do Rio Preto, Sa˜o Paulo, Brazil. Dr. Kaufman has a Career Development Award from Research to Prevent Blindness, New York, New York, USA. None of the authors has a financial or proprietary interest in any material or method mentioned. Correspondence to Robert J. Cionni MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, Ohio 45242, USA. 2003 ASCRS and ESCRS Published by Elsevier Inc.
Surgical Technique One or 2 drops of Xylocaine-MPF 1% are applied to the ocular surface several minutes before the surgical site is prepared and draped. A side-port incision is created and 0.3 to 0.5 mL of Xylocaine-MPF 1% is injected into the anterior chamber (Figure 1). Mydriasis begins immediately, enabling the surgeon to proceed within 90 seconds (Figure 2). Instillation of viscoelastic material can further enlarge the pupil. The pupil remains dilated and may continue to enlarge if intracameral epinephrine (0.3 cc of 1:1000) is added to the infusion during routine phacoemulsification, cortical aspiration, and intraocular lens implantation.
Discussion Local anesthetic agents block conduction of nerve impulses by their direct action on voltage-gated sodium channels. Injection of intracameral lidocaine acts to some extent on all nerve fibers in the anterior chamber to provide anesthesia and akinesia of the iris. Lidocaine’s effect of iris paralysis and mydriasis was noted by Lincoff et al.2 in 1985 in a patient who received an accidental intraocular injection of lidocaine without administration of topical mydriatics. The patient recovered normal 0886-3350/03/$–see front matter doi:10.1016/j.jcrs.2003.09.009
TECHNIQUES: CIONNI
Figure 1. (Cionni) Pupil size before the introduction of Xylocaine-
Figure 2. (Cionni) Enlargement of the pupil 90 seconds after injec-
MPF 1% into the anterior chamber.
tion of Xylocaine-MPF 1%.
retinal and pupillary function within 16 hours. Pupil dilation associated with instillation of lidocaine into the anterior chamber appears to result from its blocking pupil constriction to light. Epinephrine in the infusion can further dilate the pupil by acting on the ␣ receptors of the iris radial muscles.3 Xylocaine-MPF 1% causes no additional inflammation, endothelial cell loss, or mean cell size variation, and its safety has been confirmed in patients with corneal pathologies such as guttata.4–9 It is an effective topical and intracameral anesthetic agent for cataract surgery, during which the patient seems more tolerant of the operating microscope light.10–12 In our first case, the patient’s pupil had dilated to 6.5 mm during the preoperative evaluation after 2 sets of tropicamide 1% and phenylephrine 2.5%. At the beginning of the procedure, the pupil measured 1.4 mm under the operating microscope before the XylocaineMPF 1% injection. Ninety-seven seconds after 0.5 mL of Xylocaine-MPF 1% was injected into the anterior chamber, the pupil had enlarged to 6.4 mm. At the conclusion of the procedure, the pupil measured 7.4 mm. Six hours after surgery, the pupil was normally reactive, measuring 4.5 mm in room light. Our first 12 patients achieved adequate dilation for cataract surgery. The mean pupil size before dilation was 2.4 mm (range 1.5 to 3.1 mm) and after instillation of Xylocaine-MPF 1%, 6.5 mm (range 5.2 to 7.2 mm). Xylocaine-MPF 1% appears to be effective in attaining adequate pupil dilation without using routine
dilating drops before cataract surgery. The avoidance of preoperative dilating eyedrops has several advantages. There is less likelihood of superficial punctate keratopathy, which can decrease the surgeon’s intraoperative visualization and the patient’s early postoperative vision and comfort level.13 Cardiac risks are diminished since sympathetic agents are not administered.14 Pupil size and reactivity become normal more quickly after surgery, resulting in faster visual improvement. Finally, the patient’s wait time in the holding area before surgery can be reduced, improving operating room efficiency and optimizing the patient’s experience.
2282
References 1. Hejny C, Edelhauser HF. Surgical Pharmacology: Intraocular Solutions and Drugs Used for Cataract Surgery. In: Buratto L, Werner L, Zanini M, Apple D, eds, Phacoemulsification; Principles and Techniques. Thorofare, NJ, Slack, 2003; 219–246 2. Lincoff H, Zweifach P, Brodie S, et al. Intraocular injection of lidocaine. Ophthalmology 1985; 92:1587–1591 3. Catterall W, Mackie K. Local anesthetics. In: Hardman JG, Limbird LE, eds, Goodman & Gilman’s the Pharmacological Basis of Therapeutics, 10th ed. New York, NY, McGraw-Hill, 2001; 367–384 4. Iradier MT, Fernandez C, Bohorquez P, et al. Intraocular lidocaine in phacoemulsification; an endothelium and blood-aqueous barrier permeability study. Ophthalmology 2000; 107:896–900; discussion by JP Gills, 900–901 5. Garcia A, Loureiro F, Lima˜o A, et al. Preservative-free lidocaine 1% anterior chamber irrigation as an adjunct to topical anesthesia. J Cataract Refract Surg 1998; 24:403–406
J CATARACT REFRACT SURG—VOL 29, DECEMBER 2003
TECHNIQUES: CIONNI
6. Eggeling P, Pleyer U, Hartmann C, Rieck PW. Corneal endothelial toxicity of different lidocaine concentrations. J Cataract Refract Surg 2000; 26:1403–1408 7. Kim T, Holley GP, Lee JH, et al. The effects of intraocular lidocaine on the corneal endothelium. Ophthalmology 1998; 105:125–130 8. Weller A, Pham DT, Ha¨berle H. Intracamerale Ana¨sthesie mit Lidocain bei Cornea guttata. Ophthalmologe 2002; 99:29–31 9. Martin RG, Miller JD, Cox CC III, et al. Safety and efficacy of intracameral injections of unpreserved lidocaine to reduce intraocular sensation. J Cataract Refract Surg 1998; 24:961–963 10. Gills JP, Cherchio M, Raanan MG. Unpreserved lidocaine to control discomfort during cataract surgery using
11.
12. 13.
14.
topical anesthesia. J Cataract Refract Surg 1997; 23: 545–550 Koch PS. Anterior chamber irrigation with unpreserved lidocaine 1% for anesthesia during cataract surgery. J Cataract Refract Surg 1997; 23:551–554 Brierley L. Effect of lidocaine on photophobia [letter]. J Cataract Refract Surg 1999; 25:1177 Edelhauser HF, Hine JE, Pederson H, et al. The effect of phenylephrine on the cornea. Arch Ophthalmol 1979; 97:937–947 Kumar V, Schoenwald RD, Barcellos WA, et al. Aqueous vs viscous phenylephrine. I. Systemic absorption and cardiovascular effects. Arch Ophthalmol 1986; 104: 1189–1191
J CATARACT REFRACT SURG—VOL 29, DECEMBER 2003
2283