TNOA Journal of Ophthalmic Science and Research

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 56  |  Issue : 3  |  Page : 155--157

A study of effect of intracameral use of preservative-free lignocaine (1%) for pupillary dilatation during phacoemulsification surgery


Pravda Chaturvedi1, Punit Kumar Singh2, Arvind Chauhan2,  
1 Department of Ophthalmology, AIIMS, Raipur, Chhattisgarh, India
2 Department of Ophthalmology, Dr. S.N. Medical College, Jodhpur, Rajasthan, India

Correspondence Address:
Dr. Pravda Chaturvedi
D/o Smt Vandana Chaubey, 04/3, E-block, Phase 1, Landmark Towers, Badalalpur, Chandmari, Varanasi - 221 007, Uttar Pradesh
India

Abstract

Aim: The aim of the study was to assess the effect of intracameral preservative-free lignocaine (1%) on the dilatation of pupil while doing phacoemulsification surgery. Materials and Methods: A prospective study carried out on 21 patients in a tertiary care hospital. The pupil diameter was measured just before instilling intracameral preservative-free lignocaine, after 1 min and 5 min, respectively. Any mydriatic was not used either before or during the surgery. Effects were compared between male and female patients and between light- and dark-colored irides patients. Results: The diameter of pupil after instillation of intracameral lignocaine was significantly higher. The effect was more pronounced in light-colored irides. There was no difference in the pupillary diameter between both the sexes. Conclusion: Intracameral preservative-free 1% lignocaine has a fast and effective mydriatic property and with more studies, can be used as a safe alternative to topical and intracameral mydriatic while phacoemulsification.



How to cite this article:
Chaturvedi P, Singh PK, Chauhan A. A study of effect of intracameral use of preservative-free lignocaine (1%) for pupillary dilatation during phacoemulsification surgery.TNOA J Ophthalmic Sci Res 2018;56:155-157


How to cite this URL:
Chaturvedi P, Singh PK, Chauhan A. A study of effect of intracameral use of preservative-free lignocaine (1%) for pupillary dilatation during phacoemulsification surgery. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2019 Apr 26 ];56:155-157
Available from: http://www.tnoajosr.com/text.asp?2018/56/3/155/243771


Full Text



 Introduction



Lignocaine is popularly used for retrobulbar and parabulbar blocks for smooth and comfortable ocular surgeries. In an era of topical anesthesia, intracameral use of preservative-free lignocaine has increased. Pharmacologically, Lignocaine is amide-type anesthetic. Its mechanism of action involves blocking the voltage-gated fast sodium channels. It is a Class Ib antiarrhythmic and a cough suppressant.

Cataract surgery, particularly, phacoemulsification, is a troublesome surgery in undilated or small pupils. Several instruments such as Malyugin Ring and iris retractors can be used in cases of small pupil. However, their use involves a certain level of expertise. Intracameral use of sympathomimetics can give good results, but they involve serious ocular and systemic side effects. Furthermore, they are contraindicated in hypertensives. The use of preservative-free lignocaine for pupillary dilatation was accidentally discovered by Lincoff et al. when they noted iris paralysis and mydriasis on accidental intraocular injection of lignocaine.[1]

The iris color differs due to the composition of the melanin pigment granules. The degree of melanin pigment can affect the onset and duration of an intraocular drug. The degree of melanin pigment can affect the onset and duration of an intraocular drug. In a dark pigmented iris, the onset of dilatation is slower and the maximum pupil dilatation is limited because of melanin pigment binds the drug. Since the is a slow release from the melanin bound drug reservoir, the effect of drug is prolonged.[2]

In this study, we tried to assess the effect of intracameral, preservative-free lignocaine for dilatation of pupils. It can be used as an alternative to the use of mydriatics.

 Materials and Methods



The study was a prospective study carried out in a tertiary health-care system. The Ethical Committee had permitted carrying out the study process.

Senile immature cataract cases were selected. Visual acuity was checked, grading of cataract on the basis of lens opacities classification system III photographs was done, and fundus was examined. Patients with any kind of irides abnormality were excluded from the study. Color and pattern of iris was particularly taken into consideration. Age and sex were recorded. The surgery and other measurements were done by one surgeon (AC). A written and informed consent was taken from the patient.

Patients were not given any cycloplegic/mydriatic eye drops. The eye was painted and draped. Parabulbar block was given. All aseptic precautions were taken. The first measurement of pupillary diameter was done with caliper at this stage. It was labeled as 0 min. Measurements were taken out of microscope, so there was no consideration of magnification effect. A paracentesis port was created and 0.2 ml of preservative-free lignocaine (1%) was instilled in anterior chamber. The steps of phacoemulsification were carried out. Pupil diameters were measured again at 1 min and 5 min. Adrenaline was not used in the infusion fluid. Measurements were done at the level of cornea. Only those cases were considered which had no intraoperative complications. Total surgical duration was noted for each case separately.

 Results



There were 21 cases in the study, of which 13 were males and 8 were females. Mean age of 21 patients was 59.6 ± 7.8 years. Out of 21 cases, 17 had brown irides and 4 had light-colored irides. These four cases were men. None of the patients was a case of diabetes or pseudoexfoliation. Any iris abnormality was excluded. All cases had immature senile cataract.

Mean pupil diameter after 1 and 5 min of instilling lignocaine was noted and found to be significantly greater than the preinstillation size. No difference in the effect of drug was noted on the basis of gender. The dilatation was of satisfactory size and persisted long enough to carry out surgery well. The mean surgical duration was 17.7 ± 2.8 min.

Statistically, the difference was not found to be significant.

The difference between light and brown colored was found to be significant. The effect of dilatation was faster and stronger. The duration of effect could not be compared [Table 1] and [Table 2].{Table 1}{Table 2}

 Discussion



Lignocaine is a popular and very effective local anesthetic. It also has an antiarrhythmic action. Intracameral use of preservative-free lignocaine has increased for doing phacoemulsification under topical anesthesia.[3],[4] It has no inflammatory effect within eye. Nor does it harm the endothelial cells.[5],[6],[7],[8] Lee et al. had used intracameral preservative-free lignocaine in undilated phakic eyes while doing trabeculectomy surgery. They noted immediate pupillary dilatation.[9] Cionni et al. had used intracameral lignocaine to induce mydriasis in phacoemulsification surgery and thus not using any mydriatic altogether.[10] Mydriatic agents are contraindicated in a known case of angle closure glaucoma and in undiagnosed glaucoma with shallow anterior chamber. Their use is cautioned against hypertension, hyperthyroidism, and cardiac disorders.[11] Mydriatic agents have the potential to cause dangerous CNS disturbances in the pediatric patient. A known history of allergy against them also precludes their use in future. Use of preservative-free intracameral lignocaine stands as an option in cases where mydriatic agents are contraindicated.

Our study shows that intracameral use of lignocaine can be a good substitute to the use of mydriatic eye drops. There were few limitations in our study. On giving parabulbar block, pupils dilate in response to the mechanical and pharmacological effect of the anesthetic drug. A better assessment of the dilatation effect of lignocaine can be done if the surgery is performed under topical anesthesia. Magnification effect of cornea was not taken into consideration. The onset was slower to start as compared to a mydriatic but was maintained enough to complete a normal phacoemulsification surgery. More studies are required to understand the onset, duration, and weaning of lignocaine's action.

 Conclusion



Intracameral preservative-free lignocaine is a safe and efficient alternative to traditional topical cycloplegics and mydriatics during phacoemulsification surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Lincoff H, Zweifach P, Brodie S, Fuchs W, Gross S, Kornmehl E, et al. Intraocular injection of lidocaine. Ophthalmology 1985;92:1587-91.
2De Santis L, Patil PN. Pharmacokinetics. In: Mauger T, Craig EL, editors. Havener's Ocular Pharmacology. St. Louis, MI: Mosby-Year Book Inc; 1994. p. 30-2.
3Hejny C, Edelhauser HF. Surgical pharmacology: Intraocular solutions and drugs used for cataract surgery. In: Buratt OL, Werner L, Zanini M, Apple D, editors. PhacoemulsiÞcation; Principle and Techniques. Thorofare, NJ: Slack; 2003. p. 219-46.
4Gills JP, Cherchio M, Raanan MG. Unpreserved lidocaine to control discomfort during cataract surgery using topical anesthesia. J Cataract Refract Surg 1997;23:545-50.
5Weller A, Pham DT, Häberle H. Intracameral anesthesia with lidocaine in cornea guttata. Ophthalmologe 2002;99:29-31.
6Garcia A, Loureiro F, Limão A, Sampaio A, Ilharco J. Preservative-free lidocaine 1% anterior chamber irrigation as an adjunct to topical anesthesia. J Cataract Refract Surg 1998;24:403-6.
7Eggeling P, Pleyer U, Hartmann C, Rieck PW. Corneal endothelial toxicity of different lidocaine concentrations. J Cataract Refract Surg 2000;26:1403-8.
8Iradier MT, Fernandez C, Bohorquez P, Moreno E, del Castillo JB, Garcia J. Intraocular lidocaine in phacoemulsiÞcation: An endothelium and blood-aqueous barrier permeability study. Ophthalmology 2000;107:896-901.
9Lee JJ, Moster MR, Henderer JD, Membreno JH. Pupil dilation with intracameral 1% lidocaine during glaucoma filtering surgery. Am J Ophthalmol 2003;136:201-3.
10Cionni RJ, Barros MG, Kaufman AH, Osher RH. Cataract surgery without preoperative eyedrops. J Cataract Refract Surg 2003;29:2281-3.
11Fraunfelder FT, Scafidi AF. Possible adverse effects from topical ocular 10% phenylephrine. Am J Ophthalmol 1978;85:447-53.