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Should Pilocarpine Be Used Intraocularly?
HYPOPYON AND ULTRASONIC CLEANING SOLUTION
LOSS OF EFFECTIVENESS OF ANESTHETIC AGENTS OVER TIME
To the Editor: Between June 7, 1984, and September 22, 1984, we had several cases of sterile hypopyon following routine extracapsular cataract extraction with intraocular lenses. We discovered they were due to a heat stable endotoxin left on the surgical instruments after routine ultrasonic cleaning. Instructions with our Mettler Electronic Cavitator ultrasonic cleaning unit state, "Normally, the longer the same liquid is used, the better it cleans." However, our investigation proved that after three days bacterial growth in the cleaning solution can produce endotoxins that remain on the surgical instruments after autoclaving and get washed into the anterior chamber during the next operation. The endotoxins were isolated in the ultrasonic cleaning solution by Dr. James Reidy and Dr. David Apple (Center for Intraocular Lens Research, University of Utah Medical Center, Salt Lake City). They were heat stable and caused severe anterior chamber reactions in rabbits. Since we have sterilized our ultrasonic cleaner and currently change the cleaning solution daily, no further case of hypopyon have been seen. A complete report of our investigation, case histories, and Drs. Reidy's and Apple's work will be published in the near future. All surgeons should be aware of this cause for hypopyon and be aware of the procedures used to clean their own surgical instruments.
To the Editor: I read with great interest the letter by Dr. Gerald Faulkner on local anesthesia for cataract surgery (Am Intra-Ocular Implant Soc] 10:472-473, 1984), regarding the loss of effectiveness ofbupivacaine hydrochloride (Marcaine®) and/or lidocaine hydrochloride (Xylocaine®) when left exposed for some period of time. I had come to the same conclusions and his findings reenforce my own impressions.
To the Editor: The terms intraocular lens and intraocular implant are misleading and incorrect. A keratoprosthesis is an intraocular lens and a glaucoma valve is an intraocular implant. The term pseudophakos, as suggested by Norman Jaffe, indicates a false lens. The logical term is phacoprosthesis, which I suggested several years ago and is the term accepted by the Library of Congress. I understand that terms become adopted from usage but I would hope that ophthalmologists, and particularly authors, would use the more scientific term.
Frederick A. Richburg, M.D.
Louis J. Girard, M.D.
Jack Hartstein, M. D. Chesterfield, Missouri
A LENS BY ANY OTHER NAME ...
Houston, Texas
Fresno, California
SHOULD PILOCARPINE BE USED INTRAOCULARLY? To the Editor: This is in response to the letter by Dr. Louis J. Girard and coauthors (Am Intra-Ocular Implant Soc] 11:64-65, 1985), describing a method of releasing pupillary capture. The major question that I have is the use of 4% pilocarpine intraocularly. From the PDR, all the pilocarpine formulated in the United States contains the preservatives benzalkonium chloride and EDTA, which should not be used in the eye because of the preservative toxicity to the intraocular tissues. I do not believe the FDA has ever approved the use of pilocarpine intraocularly. Both acetylchloine chloride (Miochol®) and carbachol (Miostat®) have been approved by the FDA for miosis intraocularly and should be used for this procedure. Henry F. Edelhauser, Ph.D. Milwaukee, Wisconsin
170
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, MARCH 1985
LOSS OF EFFECTIVENESS OF ANESTHETIC AGENTS OVER TIME
To the Editor: Between June 7, 1984, and September 22, 1984, we had several cases of sterile hypopyon following routine extracapsular cataract extraction with intraocular lenses. We discovered they were due to a heat stable endotoxin left on the surgical instruments after routine ultrasonic cleaning. Instructions with our Mettler Electronic Cavitator ultrasonic cleaning unit state, "Normally, the longer the same liquid is used, the better it cleans." However, our investigation proved that after three days bacterial growth in the cleaning solution can produce endotoxins that remain on the surgical instruments after autoclaving and get washed into the anterior chamber during the next operation. The endotoxins were isolated in the ultrasonic cleaning solution by Dr. James Reidy and Dr. David Apple (Center for Intraocular Lens Research, University of Utah Medical Center, Salt Lake City). They were heat stable and caused severe anterior chamber reactions in rabbits. Since we have sterilized our ultrasonic cleaner and currently change the cleaning solution daily, no further case of hypopyon have been seen. A complete report of our investigation, case histories, and Drs. Reidy's and Apple's work will be published in the near future. All surgeons should be aware of this cause for hypopyon and be aware of the procedures used to clean their own surgical instruments.
To the Editor: I read with great interest the letter by Dr. Gerald Faulkner on local anesthesia for cataract surgery (Am Intra-Ocular Implant Soc] 10:472-473, 1984), regarding the loss of effectiveness ofbupivacaine hydrochloride (Marcaine®) and/or lidocaine hydrochloride (Xylocaine®) when left exposed for some period of time. I had come to the same conclusions and his findings reenforce my own impressions.
To the Editor: The terms intraocular lens and intraocular implant are misleading and incorrect. A keratoprosthesis is an intraocular lens and a glaucoma valve is an intraocular implant. The term pseudophakos, as suggested by Norman Jaffe, indicates a false lens. The logical term is phacoprosthesis, which I suggested several years ago and is the term accepted by the Library of Congress. I understand that terms become adopted from usage but I would hope that ophthalmologists, and particularly authors, would use the more scientific term.
Frederick A. Richburg, M.D.
Louis J. Girard, M.D.
Jack Hartstein, M. D. Chesterfield, Missouri
A LENS BY ANY OTHER NAME ...
Houston, Texas
Fresno, California
SHOULD PILOCARPINE BE USED INTRAOCULARLY? To the Editor: This is in response to the letter by Dr. Louis J. Girard and coauthors (Am Intra-Ocular Implant Soc] 11:64-65, 1985), describing a method of releasing pupillary capture. The major question that I have is the use of 4% pilocarpine intraocularly. From the PDR, all the pilocarpine formulated in the United States contains the preservatives benzalkonium chloride and EDTA, which should not be used in the eye because of the preservative toxicity to the intraocular tissues. I do not believe the FDA has ever approved the use of pilocarpine intraocularly. Both acetylchloine chloride (Miochol®) and carbachol (Miostat®) have been approved by the FDA for miosis intraocularly and should be used for this procedure. Henry F. Edelhauser, Ph.D. Milwaukee, Wisconsin
170
AM INTRA-OCULAR IMPLANT SOC J-VOL 11, MARCH 1985