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Postoperative intraocular pressure elevation after the use of Healon GV in pediatric cataract surgery
Postoperative Intraocular Pressure Elevation After the Use of Healon GV in Pediatric Cataract Surgery Tudith
A. Englert.
MD.
and M. Edward
Wilson.
MD
Intraocular pressure elevation after the use of viscoelastic agents in uncomplicated cataract surgery has been well documented in adults. However, pediatric patients are thought to clear residual viscoelastic agents from the anterior chamber more easily than adults, presumably because of healthier trabecular meshwork.1 We report on a series of 4 eyes of 4 children with previously normal intraocular pressure who underwent cataract extraction with primary (3 patients) or secondary (1 patient) intraocular lens implantation with Healon GV, which was complicated by marked postoperative intraocular pressure elevation (greater than 30 mm Hg). The patients, aged 5 to 14 years, had an intraocular pressure ranging from 34 to 50 mm Hg with Tonopen or applanation tonometry 1 day, postoperatively associated with nausea, eye pain, and microcystic comeal edema. Viscoelastic material was not entirely removed during surgery. Each of these cases occurred after a change in our preferred viscoelastic agent from one with less viscosity to Healon GV. Medical management controlled the elevated intraocular pressure in all cases without affecting the visual outcome. However, 1 patient with intractable nausea and vomiting required hospitalization for rehydration. With meticulous removal of all viscoelastic material at the completion of surgery, we have not documented any additional cases of postoperative pressure elevation. All surgeries were performed by the same surgeon (M. E. W.) in the period extending from March 7, 1997, to December 3 1, 1998. The cataract surgery was performed as follows: A 3.5 to 4.0~mm tunnel incision was fashioned in sclera or clear cornea. Healon GV was then placed m From tbe Department of Opbtbolmology, Medical University of South Carolina, Cbarkstm, Smrtb Cmvha. Supponed in port by an ttnnmirtcd grmzt to tbe Storm Eye htitute fi Ruearcb to RrvmtBlblbcrr, Inc. Submined Febmmy 8,1999. Revtint acqedjknc 7,1999. Reprint nqulm: M. Edward WV.m, MD, Storm Eye Institute, 167 Ashley Avenue, Cbahtm, SC 2942s (e-&l: [email protected]). 7 AAPOS 1999;3:60-1. Copyright 0 2000 by tbe Amerkan Association for Pediatrik Opbtbalmology and Strabismus. 1091-8~3lROOO $12.00 + 0 7S/l/101391
the anterior chamber. A mechanical anterior capsulotomy was performed using the vitrector. The cataract was removed using irrigation and aspiration. Healon GV was placed into the capsular bag followed by an Acrysof MA3OBA (5.5-mm optic) or Acrysof MA60BM (6.0-mm optic) lens implant. For primary implantation cases, a pars plana stab incision was made 2.5 mm posterior to the limbus. A posterior capsulectomy and anterior vitrectomy were performed using the vitrector. During the posterior capsulectomy and anterior vitrectomy, a large amount of a viscoelastic agent could easily be seen as it moved from the anterior chamber to the posterior chamber and was removed by the vitrector. In the cases reported, after the anterior vitrectomy and posterior capsulectomy were performed, no effort was made to remove any further viscoelastic agent. Subconjunctival dexamethosone was then injected, followed by atropine 1% and antibiotic-steroid ointment in all cases. No intraocular complications were encountered. The first patient, a 6-year-old girl with posterior lenticonus, underwent cataract extraction, and, on postoperative day 1, she had an intraocular pressure of 34 mm Hg with moderate eye pain and nausea. Microcystic comeal edema and l+ cell and flare were present. The intraocular pressure was controlled with timolol maleate, and no further problems related to intraocular pressure were encountered. The second patient, a 5-year-old boy with a developmental cataract, had an intraocular pressure of 45 mm Hg associated with eye pain and nausea a day after cataract surgery. Microcystic cornea1 edema and 1 to 2+ cell and flare were seen. Dorzolamide and timolol maleate relieved the pressure elevation with no further problems. The third patient, a 9-year-old boy with posterior lenticonus, had nausea, vomiting, and marked eye pain associated with an intraocular pressure of 49 mm Hg a day after cataract surgery The child was hospitalized for 1 day for rehydration, and intraocular pressure elevation was managed with tin10101 maleate, apraclonidine, and intravenous acetazolamide. The elevated pressure resolved without further problems. The last patient, a 14-year-old girl with microphthalmia and aphakia, underwent secondary intraocular lens placement with two Acrysof MA3 OBA 17-D lenses placed in the ciliary s&us in a piggyback fashion. Postoperatively, nau-
3oumnl of AAPOS I/obnte
4 N&nber
1 Fehwvy
2000
sea, vomiting, and eye pain developed because of an intraocular pressure of SO mm Hg associated with microcystic cornea1 edema and moderate cell and flare. Healon GV was visible in the deep anterior chamber with no pupillary block. Anterior chamber paracentesis immediately relieved the eye pain, and timolol maleate and acetazolamide controlled the pressure without further problems. The exact amount of residual viscoelastic agent that can cause an elevated intraocular pressure is not known. A study by Anmarkrud et a12 found that 0.1 or 0.2 mL of Healon injected into the anterior chamber of adult patients at the conclusion of planned extracapsular cataract surgery followed by topical timolol maleate did not significantly change the intraocular pressure from preoperative measurements 3 to 6 hours postoperatively. However, the intraocular pressure markedly rose by 24 hours postoperatively in these eyes, unlike those eyes in which no Healon was injected after cataract extraction.2 A study by Tanaka et al3 was done in which sodium hyaluronate (Healon) was aspirated from the anterior chamber for a duration of 5 to 20 seconds at the conclusion of cataract surgery in adult patients. The intraocular pressure was significantly higher after a S-second aspiration of Healon compared with a loor 20-second aspiration of Healon. The residual Healon concentration in the washout fluid was significantly correlated with intraocular pressure.3 It is not known precisely how viscoelastic agents cause intraocular pressure spikes. Physical characteristics of the agents as well as chemical interactions may be responsible.4 Berson et al5 found that hyaluronic acid decreases oufflow facility of the trabecular meshwork by 6S%, which is reversed with hyalmonidase (in essence “unclogging” the meshwork). The molecular size of hyaluronic acid may be directly proportional to intraocular pressure, as demonstrated by Equi et al.6 Healon GV has the highest molecular weight of any of the viscoelastic substances; there is a predisposition toward postoperative pressure elevation with Healon GV even more so than with other agents.7 However, it is this properry of Healon GV that maintains surgical space during intraocular surgery, making it especially desirable in pediatric cataract surgery. All of the cases reported above occurred after a change in our preferred viscoelastic agent f?om one with less viscosity to Healon GV Although the patients reported on are our only documented cases of a retained viscoelastic agent causing a pressure spike, many more of our past patients may have
Englert and Wilson
61
had a retained viscoelastic agent after cataract surgery and yet not had microcystic edema, eye pain, and elevated intraocular pressure. Younger patients do not always allow intraocular pressure measurement after surgery. In those cases, we have relied on the absence of cornea1 edema, eye pain, and nausea as evidence of normal intraocular pressure. Nonetheless, our cases in this report are an argument for meticulous removal of the viscoelastic agent from the eye at the end of cataract surgery in children, especially when a highly viscous agent such as Healon GV is used. The primary adverse effects, assumed to be caused by a retained viscoelastic agent in these cases, were marked intraocular pressure, eye pain, and nausea/vomiting. Although no long-term adverse effects were seen such as decreased visual acuity or increased optic nerve cupping, 1 patient required hospital admission because of the severity of nausea and vomiting, which led to dehydration. Because we have become more meticulous about complete removal of a viscoelastic agent before pars plana vitrectomy, we have documented no further cases of marked postoperative intraocular pressure elevation. In children whose intraocular pressure cannot be measured on postoperative day 1, other signs and symptoms should raise suspicion of markedly elevated intraocular pressure, particularly eye pain by history and microcystic cornea1 edema found on slit lamp evaluation. References 1. Wilson ME. Pediatric cataract surgery. In: Spaetb G, editor. Ophthalmic surgery, principles and practices. 3rd ed. Philadelphia: WB Saunders Co. In press. 2. Anmarkrud N, Bergaust B, Bulie T The quantitative effect of Healon on early postoperative intraocular pressure after exuacapsular cataract extraction with implantation of a posterior chamber lens. Acta Ophtbalmol Stand 1995;73:537-40. 3. Tanaka T, Inoue H, Kudo S, Ogawa T Relationship between postoperative intraocular pressure elevation and residual sodium hyaluronate following phacoemulsification and aspiration. J Cataract Refract Surg 1997;23:284-8. 4. Arishnoff Sk ,Dispersive and cohesive viscoelastic materials in phacoemulsification. Ophthalmic Pratt 1995;13:98-104. 5. Berson PJ, Patterson MM, Epstein DL. Obsuuction of aqueous outflow by sodium hyaluronate in enucleated human eyes. Am J Ophthalmol 1983;95:668-72. 6. Equi RA, Jumper M, Cha C, Stem R, Schwartz DM. Hyaluronan polymer size modulates intraocular pressure. J Ocul Pharmacol Ther 1997;13:289-95. 7. Hiitz W, Eckhardt HB, Kohnen T. Comparison of viscoelastic substances used in phacoemulsification. J Cataract Refract Surg 1996;22:955-9.
A. Englert.
MD.
and M. Edward
Wilson.
MD
Intraocular pressure elevation after the use of viscoelastic agents in uncomplicated cataract surgery has been well documented in adults. However, pediatric patients are thought to clear residual viscoelastic agents from the anterior chamber more easily than adults, presumably because of healthier trabecular meshwork.1 We report on a series of 4 eyes of 4 children with previously normal intraocular pressure who underwent cataract extraction with primary (3 patients) or secondary (1 patient) intraocular lens implantation with Healon GV, which was complicated by marked postoperative intraocular pressure elevation (greater than 30 mm Hg). The patients, aged 5 to 14 years, had an intraocular pressure ranging from 34 to 50 mm Hg with Tonopen or applanation tonometry 1 day, postoperatively associated with nausea, eye pain, and microcystic comeal edema. Viscoelastic material was not entirely removed during surgery. Each of these cases occurred after a change in our preferred viscoelastic agent from one with less viscosity to Healon GV. Medical management controlled the elevated intraocular pressure in all cases without affecting the visual outcome. However, 1 patient with intractable nausea and vomiting required hospitalization for rehydration. With meticulous removal of all viscoelastic material at the completion of surgery, we have not documented any additional cases of postoperative pressure elevation. All surgeries were performed by the same surgeon (M. E. W.) in the period extending from March 7, 1997, to December 3 1, 1998. The cataract surgery was performed as follows: A 3.5 to 4.0~mm tunnel incision was fashioned in sclera or clear cornea. Healon GV was then placed m From tbe Department of Opbtbolmology, Medical University of South Carolina, Cbarkstm, Smrtb Cmvha. Supponed in port by an ttnnmirtcd grmzt to tbe Storm Eye htitute fi Ruearcb to RrvmtBlblbcrr, Inc. Submined Febmmy 8,1999. Revtint acqedjknc 7,1999. Reprint nqulm: M. Edward WV.m, MD, Storm Eye Institute, 167 Ashley Avenue, Cbahtm, SC 2942s (e-&l: [email protected]). 7 AAPOS 1999;3:60-1. Copyright 0 2000 by tbe Amerkan Association for Pediatrik Opbtbalmology and Strabismus. 1091-8~3lROOO $12.00 + 0 7S/l/101391
the anterior chamber. A mechanical anterior capsulotomy was performed using the vitrector. The cataract was removed using irrigation and aspiration. Healon GV was placed into the capsular bag followed by an Acrysof MA3OBA (5.5-mm optic) or Acrysof MA60BM (6.0-mm optic) lens implant. For primary implantation cases, a pars plana stab incision was made 2.5 mm posterior to the limbus. A posterior capsulectomy and anterior vitrectomy were performed using the vitrector. During the posterior capsulectomy and anterior vitrectomy, a large amount of a viscoelastic agent could easily be seen as it moved from the anterior chamber to the posterior chamber and was removed by the vitrector. In the cases reported, after the anterior vitrectomy and posterior capsulectomy were performed, no effort was made to remove any further viscoelastic agent. Subconjunctival dexamethosone was then injected, followed by atropine 1% and antibiotic-steroid ointment in all cases. No intraocular complications were encountered. The first patient, a 6-year-old girl with posterior lenticonus, underwent cataract extraction, and, on postoperative day 1, she had an intraocular pressure of 34 mm Hg with moderate eye pain and nausea. Microcystic comeal edema and l+ cell and flare were present. The intraocular pressure was controlled with timolol maleate, and no further problems related to intraocular pressure were encountered. The second patient, a 5-year-old boy with a developmental cataract, had an intraocular pressure of 45 mm Hg associated with eye pain and nausea a day after cataract surgery. Microcystic cornea1 edema and 1 to 2+ cell and flare were seen. Dorzolamide and timolol maleate relieved the pressure elevation with no further problems. The third patient, a 9-year-old boy with posterior lenticonus, had nausea, vomiting, and marked eye pain associated with an intraocular pressure of 49 mm Hg a day after cataract surgery The child was hospitalized for 1 day for rehydration, and intraocular pressure elevation was managed with tin10101 maleate, apraclonidine, and intravenous acetazolamide. The elevated pressure resolved without further problems. The last patient, a 14-year-old girl with microphthalmia and aphakia, underwent secondary intraocular lens placement with two Acrysof MA3 OBA 17-D lenses placed in the ciliary s&us in a piggyback fashion. Postoperatively, nau-
3oumnl of AAPOS I/obnte
4 N&nber
1 Fehwvy
2000
sea, vomiting, and eye pain developed because of an intraocular pressure of SO mm Hg associated with microcystic cornea1 edema and moderate cell and flare. Healon GV was visible in the deep anterior chamber with no pupillary block. Anterior chamber paracentesis immediately relieved the eye pain, and timolol maleate and acetazolamide controlled the pressure without further problems. The exact amount of residual viscoelastic agent that can cause an elevated intraocular pressure is not known. A study by Anmarkrud et a12 found that 0.1 or 0.2 mL of Healon injected into the anterior chamber of adult patients at the conclusion of planned extracapsular cataract surgery followed by topical timolol maleate did not significantly change the intraocular pressure from preoperative measurements 3 to 6 hours postoperatively. However, the intraocular pressure markedly rose by 24 hours postoperatively in these eyes, unlike those eyes in which no Healon was injected after cataract extraction.2 A study by Tanaka et al3 was done in which sodium hyaluronate (Healon) was aspirated from the anterior chamber for a duration of 5 to 20 seconds at the conclusion of cataract surgery in adult patients. The intraocular pressure was significantly higher after a S-second aspiration of Healon compared with a loor 20-second aspiration of Healon. The residual Healon concentration in the washout fluid was significantly correlated with intraocular pressure.3 It is not known precisely how viscoelastic agents cause intraocular pressure spikes. Physical characteristics of the agents as well as chemical interactions may be responsible.4 Berson et al5 found that hyaluronic acid decreases oufflow facility of the trabecular meshwork by 6S%, which is reversed with hyalmonidase (in essence “unclogging” the meshwork). The molecular size of hyaluronic acid may be directly proportional to intraocular pressure, as demonstrated by Equi et al.6 Healon GV has the highest molecular weight of any of the viscoelastic substances; there is a predisposition toward postoperative pressure elevation with Healon GV even more so than with other agents.7 However, it is this properry of Healon GV that maintains surgical space during intraocular surgery, making it especially desirable in pediatric cataract surgery. All of the cases reported above occurred after a change in our preferred viscoelastic agent f?om one with less viscosity to Healon GV Although the patients reported on are our only documented cases of a retained viscoelastic agent causing a pressure spike, many more of our past patients may have
Englert and Wilson
61
had a retained viscoelastic agent after cataract surgery and yet not had microcystic edema, eye pain, and elevated intraocular pressure. Younger patients do not always allow intraocular pressure measurement after surgery. In those cases, we have relied on the absence of cornea1 edema, eye pain, and nausea as evidence of normal intraocular pressure. Nonetheless, our cases in this report are an argument for meticulous removal of the viscoelastic agent from the eye at the end of cataract surgery in children, especially when a highly viscous agent such as Healon GV is used. The primary adverse effects, assumed to be caused by a retained viscoelastic agent in these cases, were marked intraocular pressure, eye pain, and nausea/vomiting. Although no long-term adverse effects were seen such as decreased visual acuity or increased optic nerve cupping, 1 patient required hospital admission because of the severity of nausea and vomiting, which led to dehydration. Because we have become more meticulous about complete removal of a viscoelastic agent before pars plana vitrectomy, we have documented no further cases of marked postoperative intraocular pressure elevation. In children whose intraocular pressure cannot be measured on postoperative day 1, other signs and symptoms should raise suspicion of markedly elevated intraocular pressure, particularly eye pain by history and microcystic cornea1 edema found on slit lamp evaluation. References 1. Wilson ME. Pediatric cataract surgery. In: Spaetb G, editor. Ophthalmic surgery, principles and practices. 3rd ed. Philadelphia: WB Saunders Co. In press. 2. Anmarkrud N, Bergaust B, Bulie T The quantitative effect of Healon on early postoperative intraocular pressure after exuacapsular cataract extraction with implantation of a posterior chamber lens. Acta Ophtbalmol Stand 1995;73:537-40. 3. Tanaka T, Inoue H, Kudo S, Ogawa T Relationship between postoperative intraocular pressure elevation and residual sodium hyaluronate following phacoemulsification and aspiration. J Cataract Refract Surg 1997;23:284-8. 4. Arishnoff Sk ,Dispersive and cohesive viscoelastic materials in phacoemulsification. Ophthalmic Pratt 1995;13:98-104. 5. Berson PJ, Patterson MM, Epstein DL. Obsuuction of aqueous outflow by sodium hyaluronate in enucleated human eyes. Am J Ophthalmol 1983;95:668-72. 6. Equi RA, Jumper M, Cha C, Stem R, Schwartz DM. Hyaluronan polymer size modulates intraocular pressure. J Ocul Pharmacol Ther 1997;13:289-95. 7. Hiitz W, Eckhardt HB, Kohnen T. Comparison of viscoelastic substances used in phacoemulsification. J Cataract Refract Surg 1996;22:955-9.