Effect of carbachol on postoperative intraocular pressure

Effect of carbachol on postoperative intraocular pressure

Effect of carbachol on postoperative intraocular pressure Thomas O. Wood, M.D. B TR T xh'acap ular cataract arbachol in tilled in 125 e at the tim ex...

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Effect of carbachol on postoperative intraocular pressure Thomas O. Wood, M.D.

B TR T xh'acap ular cataract arbachol in tilled in 125 e at the tim extra tion and p t ri r chamb r I n in erti n had a tati ticall ignificant effect on lowerin th po top rati e intraocular pr UI' (lOP) at 24 hour (a era e lOP 14,0 mm H )and at 72 hour (a erage lOP 11.6 mm H ) ( P<,OOl), The percenta e of pati nt \ ith an a ut lOP ele ation at 24 h ur \ a al 0 i nificantl reduced: carbachol 1O~ er' u conh'ol33~ (p= ,001), arbachol' prol n ed 10\ erin of po toperati e lOP ma incr-ea e the afety of catar'act urger , particularl in patient \ ith com pI' mi ed ptic ner K

Word: carbachol, p : top .-ati\

Postoperative intraocular pressure (lOP) elevation has been reported in approximately 25% of eyes having intracapsular cataract extraction and as many as 55% of eyes having extracapsular cataract extraction. 1-5 When alphachymotrypsin was used in intracapsular cataract extraction, as many as 75% of patients developed an acute postoperative lOP rise. 6 Timolol has been found ineffective in altering the acute lOP rise following extracapsular cataract extraction. 4.5 Acetylcholine has a lowering effect for approximately six hours but is ineffective at 24 hours. 7 Intracameral carbachol has been shown to have a significant lowering effect on the postoperative lOP from three to 24 hours. 8 This study was conducted to examine the effect of intracameral carbachol 0.01 % on postoperative lOP on the first and third days postoperatively as well as its effect on the number of patients who have an lOP elevation 24 hours after extracapsular cataract extraction and posterior chamber lens insertion.

SUBJECTS AND METHODS One hundred twenty-five eyes having planned extracapsular cataract extraction with posterior chamber lens insertion were studied. Fifty-one eyes from a previously published study that had had extracapsular

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intrao 'ular pr

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cataract extraction and posterior chamber lens insertion prior to the routine use of hyaluronic acid were used as comparative control eyes. 4 In the prospective consecutive carbachol group, hyaluronic acid was used to facilitate surgery and was removed at the end of the procedure . Carbachol 0.25 ml of 0.01 % was instilled intracamerally prior to wound closure, and again after the hyaluronic acid had been removed. In the control group, neither hyaluronic acid nor any pressure lowering substance (i.e., timolol, pilocarpine gel,5 acetylcholine, or carbachol) was used. Postoperatively, subconjunctival dexamethasone 2 mg was given to all eyes; mydriatics were not used. Eyes with preoperative glaucoma were excluded from the study. Intraocular pressure three days postoperatively was not available in the control group.

RESULTS The average preoperative lOP was 18.7 mm Hg in the control group and 18.4 mm Hg in the carbachol group. In the control group, the average lOP on day one was 20.7 mm Hg. In the carbachol group, the average lOP was 14.0 mm Hg (P<.OOl) 24 hours postoperatively and 11.6 mm Hg (P<.OOOl) 72 hours postoperatively (Figure 1 and Table 1).

Supported by Baptist Memorial Hospital Clinical Innovations Fund, Memphis, Tennessee . Reprint requests to Thomas 0. Wood , M.D., 66 North Pauline , Suite 438, Memphis. Tennessee 38105. 654

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Table 1. Intraocular pressure response. Group

Number of Points

Preoperative Mean lOP (mm Hg)

Postoperative lOP at 24 hours (mm Hg)

Postoperative lOP at 72 hours (mm Hg)

Carbachol

125

18.4

14.0 (n = 95)

11.7 (n=30)

51

18.7

20.7

Not available

Control

(P<.OOI)

Fig. 1.

(Wood) Three days after ECCE and posterior chamber IOL and intracameral carbachol, the lOP was 12 mm Hg; note persistent extreme miosis.

Some eyes in each group developed an acute lOP rise. In the control group, on the first postoperative day, 33% of patients had lOPs greater than 23.0 mm Hg; the average was 3l.0 mm Hg. In the carbachol group, 10% of patients developed an lOP elevation; the average was .33.8 mm Hg (Table 2). The number of patients that developed an acute lOP rise was significantly reduced with the use of intracameral carbachol (p= .001).

DISCUSSION Acute postoperative lOP elevation can result from many factors: compromised outflow secondary to trabecular meshwork edema or retained cortical material, position of the incision relative to the limbus, or a Table 2. Percentage of lOP elevation on the first postoperative day. Group

Percentage> 23 mm Hg

Mean lOP

Carbachol

10

33.8 mm Hg

Control

33

31.0 mm Hg

(P = .001)

(P<.OOOI)

compromised angle preoperatively.2.9 Timolol has been found to be effective in controlling lOP after intracapsular cataract extraction but has no effect 24 hours after extracapsular cataract extraction. 4,.5,10 Improved surgical technique and outpatient surgery has created a corresponding decrease in the frequency of examinations postoperatively. One of the main concerns following intraocular surgery is the acute rise in lOP postoperatively. Following cataract surgery, the lOP peaks in the first six to seven hours. l l Anterior ischemic optic neuropathy has been linked to increased postoperative IOp'12 A predictable method that significantly lowers early postoperative lOP may be a useful clinical tool. lntracameral carbachol has a statistically significant postoperative lOP lowering effect from three to 24 hours. 8 In this study, carbachol produced a significant reduction in the number of eyes (10% vs 33%) that developed an acute postoperative lOP rise at 24 hours. Carbachol's resistance to hydrolysis by cholinesterase causes the pressure reduction to remain significant on the third postoperative day; some eyes exhibited persistent miosis three days postoperatively (Figure 1).13,14,15 The instillation of carbachol may add to the safety of outpatient cataract surgery, particularly in eyes with compromised optic nerves. 12 REFERENCES 1. Gormaz A: Ocular tension after cataract surgery; with special reference to the phenomenon of/ate hypotony. Am] Ophthalmol 53:832-841, 1962 2. Tuberville AW, Tomoda T, Wood TO: Intraocular pressure elevation after cataract surgery. In:Emery JM, Jacobson AC, eds, ClUTent Concepts in Cataract Surgery; Selected Proceed-

3. 4.

5. 6.

ings of the Eighth Biennial Cataract Surgical Congress. Norwalk, CT, Appleton-Century-Crofts, 1984, pp 267-269 Galin MA, Lin LL-K, Obstbaum SA: Cataract extraction and intraocular pressure. Trans Ophthalmol Soc UK 98: 124-127. 1978 Tomoda T, Tuberville AW, Wood TO: Timolol and postoperative intraocular pressure. Am Intra-Ocular Implant Soc] 10:180-181, 1984 Ruiz RS, Wilson CA, Musgrove KH, Prager TC: Management of increased intraocular pressure after cataract extraction. Am] Ophthalmol 103:487-491, 1987 Kirsch RE: Glaucoma after cataract extraction associated with use of alpha-chymotrypsin. In: Theodore FH, ed, Complications After Cataract Surgery. Boston, Little, Brown and Co, 1965, pp 233-247

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7 . Hollands RH, Drance SM , Schulzer M: The effect of acetylcholine on early postoperative intraocular pressure. Am] Ophthalmoll03:749-753 , 1987 8. Hollands RH, Drance SM , Schulzer M: The effect of intracameral carbachol on intraocular pressure after cataract extraction. Am] Ophthalmol 104:225-228, 1987 9. Rothkoff L, Biedner B, Blumenthal M: The effect of corneal section on early increased intraocular pressure after cataract extraction. Am] Ophthalmol 85:337-338, 1978 10. Obstbaum SA, Galin MA: The effects of timolol on cataract extraction and intraocular pressure . Am ] Ophthalmol 88: 1017-1019, 1979 11 . Rich W], Radtke ND, Cohan BE : Early ocular hyperten-

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sion after cataract extraction. Br ] Ophthalmol 58:725-731 , 1974 Hayreh SS : Anterior ischemic optic neuropathy. IV. Occurrence after cataract extraction. Arch Ophthalmol 98:14101416, 1980 Beasley H, Borgmann AR, McDonald TO, Belluscio PR: Carbachol in cataract surgery. Arch Ophthalmol 80:39-41 , 1968 Beasley H: Miotics in cataract surgery. Arch Ophthalmol 88:49-51, 1972 McDonald TO, Beasley C , Borgmann A, Roberts D: Intraocular administration of carbamylcholine chloride . Ann Ophthalmol 1:232-239, 1969

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