1. Anterior capsule and cortical lens discolouration with intracameral phenylephrine during cataract surgery
Anant Sharma MD, Shafi Balal MBBS, Nisha Nesartanam MBBS, Gnanapragasam Nithyanandarajah MBBS, Jonathan Massie, Jonathan Than MBBS Moorfields Eye Hospital, Bedford, United Kingdom
BACKGROUND
Methods
Discussions
Intraoperative preservative containing phenylephrine (PE) is used in cataract surgery to help dilate the pupil and/or make the iris more rigid in floppy iris syndrome (IFIS) . Preservatives are known to be toxic to the corneal endothelium. A safety alert was issued for intracameral epinephrine use because of corneal decompensation; the effect was attributed to the bisulfite preservative in the solution. Bisulfite is present in intracameral PE mixtures commonly used, including 'Minims preservative free'.
We report 20 consecutive cases of intraoperative PE causing capsule and anterior cortical fibre staining. This is the first time this has been reported. Intracameral PE was used in all 20 patients to dilate the pupil. The intracameral PE was made by diluting 0.3mls PE 10% Minims to 1ml or 2ml with balanced salt solution and adrenaline (1mg of adrenaline was added to 500mls of balanced salt solution). Approximately 0.2mls of the PE solution was used.
PE is known to cause cataracts and free radicals, the latter, along with preservatives in solution, may cause long term damage including to the endothelium. Intracameral PE is known to be safe and has not been associated with toxic anterior segment syndrome but may cause subclinical damage to the endothelium through its free radical mechanism.
RESULTS
Capsular and subcapsular cortical spoke like pattern staining occurred in all 20 cases. Figure 1 shows comparison of the same eye, pre and post PE staining. There is initial staining of the capsule, followed by the staining of the anterior subcapsular cortical lens fibres; this is irrespective of the type of cataract. The subcapsular anterior cortical fibres stains are lifted during capsulorhexis (Figure 2). The stain was limited to the area of contact with the capsule (the capsule under the iris did not stain). Removal of the anterior capsule also appeared to remove a large part of the stain.
Figure 2. (a) pre-folding stain (b) stain on folded capsulorhexis
conclusions
PE appears essential for safe cataract surgery in selected cases. PE causes sub-capsular cortical stain. Discussion with surgeons in our department revealed that those who leave intracameral PE for approximately 20 seconds or longer in the eye have also observed this staining in all cases. Further work needs to be done on the effect of intracameral PE in the eye.
Figure 1. (a) Pre-staining (b) Post capsular staining
References: Claoué, C. M. Phenylephrine-induced reversible cataract in the mouse. J. R. Soc. Med. 80, 694–695 (1987). Lockington, D. et al. Presence of free radicals in intracameral agents commonly used during cataract surgery. Br. J. Ophthalmol. 94, 1674–1677 (2010). ASCRS issues clinical alert on intracameral alpha agonists. April Hull DS, Chemotti MT, Edelhauser HF, Van Horn DL, Hyndiuk RA. Effect of epinephrine on corneal endothelium. Am J Ophthalmol 1975; 79:
The authors declare no conflicts of interest