Cataract surgery in children using intracameral mydriatic.

PURPOSE: To study the pupil dynamics with premixed intracameral anesthetic mydriatic combination of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) in pediatric cataract surgery. METHODS: Consecutive children aged ≤12 years planned for cataract surgery were recruited. A commercially available premixed combination of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) was injected at the beginning of surgery without any topical/infusion drugs for mydriasis. Pupil sizes at various points of surgery were studied. RESULTS: We recruited 75 patients with a mean age of 24.3 ± 33.4 months (range: 1 month-11 years). Adequate mydriasis with a single injection was achieved in 93.5% (n = 73 eyes of 70 patients) without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.8 ± 0.79 to 6.1 ± 1.4 mm after injection (mean change of 4.2 ± 1.25 mm from baseline). The mean variability in pupillary diameter was 0.73 ± 1.3 mm. In five eyes, good dilatation was not possible even after repeat injection. CONCLUSION: Fixed-dose premixed intracameral injection is effective in pupil dilatation. It alleviates the need for any topical dilators or additional intraoperative supplementation for pediatric cataract surgery.

Postoperative anterior uveitis in a patient submitted to combined treatment with cataract surgery and iStent inject®. How to manage? / Uveíte anterior no pós-operatório de facectomia combinada com implante de iStent inject®. Como manejar?

ABSTRACT Minimally invasive glaucoma surgeries are surgical treatment alternatives for glaucoma aimed at reducing intraocular pressure with a better safety profile compared to traditional trabeculectomy. However, in spite of less invasive techniques, complications may develop in any surgical procedure. To the best of our knowledge, this is the first case report of anterior uveitis following combined treatment with cataract surgery and iStent inject® which addresses the management of postoperative inflammation.

RESUMO As cirurgias minimamente invasivas para glaucoma consistem em uma opção de tratamento cirúrgico para glaucoma, a qual promove redução da pressão intraocular com melhor perfil de segurança do que a trabeculectomia. Todavia, complicações são inerentes à realização de procedimentos cirúrgicos, apesar do uso de técnicas menos invasivas. Este é o primeiro relato que apresenta um caso de uveíte anterior após cirurgia combinada de catarata e iStent inject®, além de orientações quanto ao manejo do quadro inflamatório.

Systemic adverse events after screening of retinopathy of prematurity with mydriatic.

PURPOSE: To evaluate systemic adverse events after screening for retinopathy of prematurity (ROP) performed with mydriatic. METHODS: This was a retrospective case series study. Medical records of consecutive patients who underwent screening for ROP with 0.5% phenylephrine and 0.5% tropicamide eyedrops were retrospectively reviewed. The score of abdominal distention (0-5), volume of milk sucked and volume of stool, along with systemic details (pulse and respiration rates, blood pressure and number of periods of apnea) were collected at 1 week and 1 day before ROP examination, and at 1 day after examination. Results were compared between the days before and after examination. Correlation between body weight at the time of examination and the score of abdominal distention was examined. The numbers of infants with abdominal and/or systemic adverse events were compared between pre- and post-examination periods. RESULTS: Eighty-six infants met the inclusion criteria. The score of abdominal distention increased from 2.0 at 1 day before examination to 2.3 at 1 day after examination (p = 0.005), and the number of infants who had worsened abdominal distension increased after examination (p = 0.01). Infants with lower body weight had a higher score of abdominal distention (p < 0.0001, r = -0.57). The number of infants with reduced milk consumption increased after examination (p = 0.0001), as did the number of infants with decreased pulse rate (p = 0.0008). CONCLUSIONS: Screening for ROP with mydriatic may have adverse effects on systemic conditions. Infants should be carefully monitored after ROP screening with mydriatic.

Ocular surface temperature measurement in diabetic retinopathy.

Infrared thermography provides functional imaging by picturing the temperature pattern of the region imaged. The temperature correlates to the blood flow pattern and is used in the diagnosis of diseases like breast cancer, peripheral vascular disorders, diabetic neuropathy and fever screening. In the present study, the usage of ocular thermography for diagnosis of diabetic retinopathy is explored. Ocular thermograms using infrared imaging camera were obtained for normal subjects (80 volunteers - 40 males and 40 females) age groups 21-30, 31-40, 41-50 and 51-60 years, non-proliferative diabetic retinopathy (NPDR) patients (50 volunteers -25 males and 25 females) and proliferative diabetic retinopathy (PDR) patients (20 volunteers -10 males and 10 females) belonging to age group of 51-60 years. The temperature at various points of interest (POIs) and horizontal temperature profiles were studied. Ocular surface temperature (OST) and effect of eye dilation on OST was studied for control, age matched NPDR and PDR. Statistical analyses were carried out to find the significance of correlation between OST of controls and NPDR and PDR. The global minimum temperature on the ocular surface for controls (21-60 years) was found to be at cornea which is about 34.79 ± 0.68 °C, and maximum at the inner canthus viz. 36.08 ± 0.62 °C. Dilation studies showed an average increase of 0.82 ± 0.13 °C in cornea and 0.75 ± 0.14 °C in conjunctiva and limbus (p < 0.001). The temperature of cornea is around 33.22 ± 0.12 °C and 32.64 ± 0.12 °C for NPDR and PDR patients respectively, in the age group of 51-60 years. OST of NPDR patients was 0.60 ± 0.15 °C lesser than that of age matched normal eyes (p < 0.001) at cornea and limbus regions and 0.71 ± 0.20 °C at inner canthus. The OST of PDR patients was lesser than age matched controls by 1.18 ± 0.12 °C at cornea, 0.9 ± 0.13 °C at inner canthus and 1.0 ± 0.14 °C at other POIs. During dilation studies a positive variation of 0.61 ± 0.12 °C in cornea and 0.48 ± 0.13 °C in conjunctiva and limbus was observed (p < 0.001) in NPDR eyes. Similarly an average increase of 0.62 ± 0.11 °C in cornea and an average increase of 0.47 ± 0.15 °C in conjunctiva and limbus were observed (p < 0.001) in PDR eyes. The OST of NPDR and PDR patients was less compared with age matched counterparts in both pre and post dilation studies. Dilation of eye showed increase in OST for both controls and diabetic retinopathy patients. The degree of increase is less compared with controls. The variation in OST observed during pre and post dilatation studies of diabetic retinopathy patients is a functional marker of pathology, and can be used as a parameter for diagnosis.

Stable Mydriasis After Intracameral Injection of a Combination of Mydriatics and Anesthetic During Cataract Surgery: A Real-Life, Multicenter Study.

Purpose: To evaluate the effect of Mydrane (contains tropicamide, phenylephrine hydrochloride, and lidocaine hydrochloride) on time needed to induce mydriasis and mydriasis stability during cataract surgery. Methods: This was an observational, non-interventional, multicenter study of patients undergoing cataract surgery who received Mydrane for mydriasis and intraocular anesthesia. The study was conducted at seven ophthalmology departments at university hospitals in Poland. Patients admitted for cataract surgery within a 2-week period were asked to participate in the study. Patients whose pupils dilated to a diameter ≥6 mm after topical mydriatic administration during preoperative examinations were scheduled to receive Mydrane and included in the registry. No additional inclusion criteria were used. Patients' medical histories, examination results, and operative details were recorded. Pupil diameter was measured during surgery. Surgeons were asked to complete a Likert-based survey in parallel. Results: A total of 307 patients were enrolled. The mean pupil diameter was 7.0 ± 1.0 mm before capsulorhexis and 6.9 ± 1.2 mm before lens implementation. A pupil diameter ≥6 mm was achieved in 91.9% and 87.6% of patients before capsulorhexis and lens implantation, respectively. We asked 58 surgeons whether they agreed with the statement "Mydriasis was obtained in a short time after the administration of Mydrane"; the surgeons agreed with this statement after 92.2% (283/307) of surgeries. In addition, after 88.2% of surgeries, the surgeons agreed with the statement "Mydriasis was stable after the administration of Mydrane." Conclusions: Mydriasis was rapidly and stably obtained after Mydrane injection, as demonstrated by pupil diameter measurements during surgery and surgeons' feedback.

Mydrane intracameral injection site can be an alternative to mydriatic drops instillation in cataract surgery.

The aim of this study is to compare Mydrane (combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1%) and mydriatic drops (tropicamide 1% and phenylephrine 10%) used for cataract surgery in terms of efficacy in pupil dilation and impact on corneal endothelial cell density (CD) and central corneal thickness (CCT). Prospective study including 64 eyes of 64 patients that underwent phacoemulsification with intraocular lens implantation. Patients were randomized into two groups: Mydrane group received: tropicamide and phenylephrine one day preoperatively and Mydrane during the surgery. Reference group received: tropicamide and phenylephrine preoperatively. Pupil size was measured only in Mydrane group, in the same eye of the same patient one day preoperatively after mydriatic drops were given and during the surgery, after intracameral Mydrane injection. CD and CCT were evaluated one day preoperatively and one month postoperatively in all patients and compared between Mydrane and reference groups. The results show CCT and CD significantly decreased after surgery in both groups. There is no difference in this decrease between groups. In Mydrane group there was no difference in dilated pupil diameter between Mydrane and mydriatic drops. Gender, diabetes mellitus, POAG, alpha-1 blocker treatment failed to affect pupil dilation obtained with Mydrane. Cataract surgery affects CCT and CD regardless of which mydriatic protocol had been used. Pupil diameter was similar after drops instillation and after Mydrane injection in all patients from the Mydrane group.

Pupil expansion device use and operative outcomes with topical dilation vs intracameral epinephrine in resident-performed cataract surgery.

PURPOSE: To compare the use of topical dilation drops vs topical drops with the addition of intracameral epinephrine in resident-performed cataract surgery and the effects on pupil expansion device (PED) use, surgical costs, and surgical times. SETTING: Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA. DESIGN: Retrospective chart review. METHODS: Resident-performed primary cataract surgical cases using topical dilation drops only or drops with the addition of intracameral epinephrine were analyzed for PED use, surgical time, and costs in all patients and in patients with a history of tamsulosin use. RESULTS: In the topical group, PEDs were used in 31.1% of cases compared with 13.5% of cases in the intracameral group (P < .0001). History of tamsulosin use was noted in about one third of cases in both groups. For patients with a history of tamsulosin use, PED use decreased from 52.7% in the topical cases to 17.9% in the intracameral group (P < .0001). Surgical times were on average 7.1 minutes slower with PED use than without PED use. There was a medication savings of $50.44 USD per case in the intracameral group compared with the topical group. Factoring in the $100 to $130 USD per PED used, total surgical costs were $19 267 USD less in the intracameral group over 6 months. CONCLUSIONS: Intracameral epinephrine with lidocaine decreases the need for PED use during cataract surgery, lowers intraoperative costs, and improves efficiency compared with topical dilation drops alone.

[Same-eye comparison of pupillary dilation with an intraoperative standardized intracameral combination of mydriatics (Mydrane®) versus a preoperative ophthalmic (Mydriasert®) in standard cataract surgery in non-diabetic patients (French translation of the article)]. / Comparaison intra-individuelle de la dilatation pupillaire par une solution intracamérulaire standardisée combinée de mydriatiques (Mydrane®) en peropératoire versus un insert ophtalmique (Mydriasert®) en préopératoire dans la chirurgie de la cataracte standard de patients non diabétiques.

INTRODUCTION: Cataract surgery is the most commonly performed surgery in the world, and its success depends in part on the quality of mydriasis. PURPOSE: To compare, for the same eye, the pupillary dilation obtained with Mydrane® (standardized intracameral solution of 0.02% tropicamide, combined with 0.31% phenylephrine and 1% lidocaine) intraoperatively versus Mydriasert® (0.28mg tropicamide insert and 5.4mg phenylephrine) with a contact time between 45 and 60 minutes in the preoperative period. METHODS: Single center prospective study from November 2016 to January 2018 at the Laveran Army Instructional Hospital in Marseille. Patients referred for surgery were dilated at the preoperative consultation with Mydriasert®. The pupillary diameter after 45-60 minutes of contact with the insert was manually measured, by two different examiners, through the "iris image" tab of the Pentacam® elevation topography. Patients were dilated on the day of their cataract surgery with 0.2cc of Mydrane® injected in the anterior chamber through a paracentesis. Thirty seconds later, prior to injection of viscoelastic, an eye photograph was taken by screen capture. The pupillary diameter was evaluated by two different examiners with to the Piximeter 5.9 metrology software. The difference in pupil dilation between Mydriasert® and Mydrane® was tested with the paired series Student t-test. RESULTS: In total, 111 eyes of 82 patients were included. Mydriasert® achieved a mean pupillary dilation of 7.21±0.79mm. The mydriasis obtained with Mydrane® averaged 6.35±0.8mm. This difference of 0.86mm was statistically significant (P<0.001) with a confidence interval of 95% [-0.97; -0.74]. CONCLUSION: On average, Mydrane® dilates the pupil less than Mydriasert®. However, the mydriasis obtained with Mydrane® remains comfortable for the performance of the capsulorhexis. It helps save preoperative time and affords additional anesthetic to the cataract surgery. Nevertheless, the use of Mydriasert® is beneficial when extra mydriasis is required.

Tropicamide/Phenylephrine/Lidocaine Intracameral Injection: A Review in Cataract Surgery.

Tropicamide 0.02%/phenylephrine 0.31%/lidocaine 1% injectable solution (Mydrane®) is the first fixed-dose mydriatic/anaesthetic combination approved for intracameral use in adults undergoing cataract surgery. In a phase 3 trial in this setting, intracameral tropicamide/phenylephrine/lidocaine was at least as effective as a standard topical regimen of tropicamide plus phenylephrine in enabling successful capsulorhexis without the use of additional mydriatics. The intracameral preparation, which is administered via a single injection, provides rapid and sustained mydriasis through to the end of surgery, with recipients spending around half as long in preoperative/surgery rooms as standard topical regimen recipients in the phase 3 study. Moreover, significantly more of the intracameral than topical regimen recipients were free from pain or pressure in the eye/orbit before intraocular lens (IOL) implantation and had an IOL implanted without complications. Intracameral tropicamide/phenylephrine/lidocaine also displayed mydriatic efficacy in patients with diabetes in this trial. Overall, the preparation was generally well tolerated, with no serious adverse events leading to hospitalization or permanent vision loss. Thus, tropicamide/phenylephrine/lidocaine injectable solution is an emerging option for mydriasis/anaesthesia in adults undergoing cataract surgery.

Evaluation of changes in retinal and choroidal thickness using spectral domain optical coherence tomography in unilateral non granulomatous acute anterior uveitis.

PURPOSE: To assess retinal and choroidal thickness changes in eyes with a first episode of unilateral non granulomatous acute anterior uveitis (AU). METHODS: Thirty-one patients with acute unilateral non granulomatous AU who had undergone spectral domain optical coherence tomography (SD-OCT) of both eyes were included in this retrospective study. Retinal thickness (RT) as defined by the Early Treatment Diabetic Retinopathy Study (ETDRS) and subfoveal choroidal thickness (SFCT) obtained by SD-OCT were recorded. Healthy fellow eyes of the patients served as the control. RESULTS: A significant thickening in 1mm of ETDRS subfield and in subfoveal choroid was observed in eyes with acute AU when compared with the unaffected fellow eyes (P=0.005 and P<0.00001, respectively). RT and SFCT of affected eyes did not show a significant difference in terms of HLA-B27 antigen presence or absence (P>0.05, for all). CONCLUSIONS: Significant posterior segment changes were detected in eyes with acute unilateral non granulomatous AU.

Acanthamoeba keratitis in Mexico: Report of a clinical case and importance of sensitivity assays for a better outcome.

Acanthamoeba keratitis (AK) is a sight-threatening corneal infection. The early symptoms include redness, pain, photophobia and intense tearing. Chronic infection usually progresses to stromal inflammation, ring ulcers, corneal opacification and hypopyon. Here we document an AK case in a high myopic 38-year-old woman from Mexico City, with a history of wearing contact lenses while swimming. Corneal scrapes cultures were positive only for amoebae, consequently a treatment including netilmicin 0.3% and oral itraconazole 100 mg/12 h was prescribed. The infection was resolved after 8 months, leaving a slight leucoma outside the visual axis, with a visual acuity of 20/150. In the laboratory, the amoebic isolate was axenized in PYG medium, with an optimal growth at 30 °C, and was identified morphologically as Acanthamoeba polyphaga according to the taxonomic criteria of Page (1988) and placed in the T4 group by genotyping. The virulence of this strain (40%) was determined by intranasal inoculation of 1 × 106/20 µl trophozoites in BALB/c mice recovering from brain, proving their invasion ability and by the interaction with monolayers of epithelial cells of the established MDCK line of canine kidney origin (1:2 ratio of interaction), at 1, 3, 6, 8 and 24 h; trophozoites migrated to cell junctions inducing few lytic zones. In addition to the biological characterization, in vitro drug sensitivity tests were performed using chlorhexidine, itraconazole, netilmicin and voriconazole. Results revealed that voriconazole was the most effective compound. A. polyphaga remains as one of the most frequently isolated species producing AK. The treatment of AK case using netilmicin and oral itraconazole solved the disease, but the healing process was wide-ranging (8 months). The use of voriconazole and chlorhexidine may be an alternative treatment of future AK cases in Mexico.

Pupil dilation dynamics with an intracameral fixed combination of mydriatics and anesthetic during cataract surgery.

PURPOSE: To compare the pupil dynamics of an intracameral combination of 2 mydriatics and 1 anesthetic (Mydrane) to a standard topical regimen for cataract surgery. SETTING: Sixty-two centers in Europe and 6 centers in Algeria. DESIGN: Prospective case series. METHODS: Pupil size measurements were performed in 2 randomized studies (phase 2 and phase 3) under masked conditions (recorded videography, masked reading center). The outcomes in the phase 2 study supported evaluation of the timeframe to obtain pupil dilation and the phase 3 study provided results on mydriasis stability. RESULTS: Phase 2 and phase 3 comprised 139 patients and 591 patients, respectively. After intracameral combination administration, 95% of the pupil dilation was achieved within a mean of 28.6 seconds ± 4.6 (SD). At the beginning of capsulorhexis creation, the mean pupil diameter was larger than 7.0 mm in both groups. The intraoperative pupil diameter remained stable in the intracameral combination group and decreased in the topical group. The mean change in pupil size just before capsulorhexis to the end of surgery (just before cefuroxime injection) was -0.22 ± 0.72 mm and -1.67 ± 0.98 mm, respectively. No clinically significant change in pupil diameter (change <1.0 mm) occurred in the majority of the intracameral combination group (89.3%) compared with the topical group (26.8%). CONCLUSIONS: Intracameral combination of 2 mydriatics and 1 anesthetic is an alternative to topical mydriatics for cataract surgery. The prompt onset of pupil dilation and the stable mydriasis induced by this drug combination improved the intraoperative conditions during crucial steps, such as intraocular lens implantation.

Budget impact model of Mydrane®, a new intracameral injectable used for intra-operative mydriasis, from a UK hospital perspective.

BACKGROUND: During cataract surgery, maintaining an adequate degree of mydriasis throughout the entire operation is critical to allow for visualisation of the capsulorhexis and the crystalline lens. Good anaesthesia is also essential for safe intraocular surgery. Mydrane® is a new injectable intracameral solution containing two mydriatics (tropicamide 0.02% and phenylephrine 0.31%) and one anaesthetic (lidocaine 1%) that was developed as an alternative to the conventional topical pre-operative mydriatics used in cataract surgery. This study aimed to estimate the budget impact across a one year time frame using Mydrane® instead of topical dilating eye drops, for a UK hospital performing 3,000 cataract operations a year. METHODS: A budget impact model (BIM) was developed to compare the economic outcomes associated with the use of Mydrane® versus topical drops (tropicamide 0.5% and phenylephrine 10%) in patients undergoing cataract surgery in a UK hospital. The outcomes of interest included costs and resource use (e.g. clinician time, mydriasis failures, operating room time, number of patients per vial of therapy etc.) associated with management of mydriasis in patients undergoing cataract surgery. All model inputs considered the UK hospital perspective without social or geographical variables. Deterministic sensitivity analyses were also performed to assess the model uncertainty. RESULTS: Introduction of Mydrane® is associated with a cost saving of £6,251 over 3,000 cataract surgeries in one year. The acquisition costs of the Mydrane® (£18,000 by year vs. £3,330 for eye drops) were balanced by substantial reductions in mainly nurses' costs and time, plus a smaller contribution from savings in surgeons' costs (£20,511) and lower costs associated with auxiliary dilation (£410 due to avoidance of additional dilation methods). Results of the sensitivity analyses confirmed the robustness of the model to the variation of inputs. Except for the duration of one session of eye drop instillation and the cost of Mydrane®, Mydrane® achieved an incremental cost gain compared to tropicamide/phenylephrine eye drops. CONCLUSIONS: Despite a higher acquisition cost of Mydrane®, the budget impact of Mydrane® on hospital budgets is neutral. Mydrane® offers a promising alternative to traditional regimes using eye drops, allowing for a better patient flow and optimisation of the surgery schedule with neutral budget impact.

An evaluation of intracameral mydriasis for routine cataract surgery.

BACKGROUND: Intracameral Mydrane might facilitate a more streamlined cataract service and improve the patient experience. There is limited 'real-world' evidence of its use in a UK setting. METHODS: As part of a local evaluation of cataract surgery using intracameral Mydrane (group 2; n=60), data were collected on intraoperative pupil size and postoperative visual acuity (VA), as well as the rate of mechanical pupil dilation, intraoperative floppy iris syndrome (IFIS) and complications. Preoperative and theatre turnaround time was recorded and patients completed a validated measure of satisfaction postoperatively. Data were compared with a previous cohort subjected to the existing standard regime of preoperative topical mydriatics (group 1; n=60). RESULTS: Postoperative VA was comparable between groups (0.09±0.16 vs 0.08±0.15; p=0.59). Pupil size in group 2 was 7.0±1.0 mm prior to capsulorhexis and 6.5±0.29 mm after cortical aspiration, with a smaller pupil in patients on alpha-antagonists (4.7±1.1 mm; p=0.004) at this later time point. Comparing group 2 with group 1, preoperative waiting was less (87 vs 146 min; p<0.0001) and satisfaction was higher (76.0±11.2 vs 66.3±8.6; p<0.0001), although theatre turnaround time was longer (25 min vs 22 min). CONCLUSION: Intracameral mydriasis was clinically effective in most patients undergoing cataract surgery and might be associated with an improved patient experience and a more streamlined preoperative flow. Mydrane represents a licensed alternative to the off-label use of other intracameral mydriatic agents, but was not judged to be a cost-effective intervention for routine use in this particular setting.

Ocular tolerance in rabbits after intracameral administration of a fixed combination of tropicamide, phenylephrine, and lidocaine with and without rinsing.

PURPOSE: To evaluate the safety and tolerability of a single intracameral administration of a combined mydriatic (tropicamide and phenylephrine) and anesthetic (lidocaine) formulation (Mydrane) with or without rinsing. SETTING: Iris Pharma, La Gaude, France. DESIGN: Experimental study. METHODS: Sixty pigmented rabbits received 100 µL or 200 µL of the combination product or a placebo (sodium chloride 0.9%) by intracameral injection. For the combination product, separate groups were included with and without rinsing after administration. From day 1 day to day 7, assessments included general clinical and ocular observations, pupil diameter measurements, corneal assessments, confocal microscopy, and electroretinography (ERG). Necropsy examinations were performed at study completion at day 8. RESULTS: Rapid mydriasis, stable 24 minutes after injection and returning to baseline levels by day 1, was induced in all groups that received the combination mydriatic and anesthetic drug. Rinsing had no effect. The combination product induced no adverse effects on the anterior or posterior segment of the eye (ie, no increased corneal thickness and endothelial cell loss, no abnormalities in ERG). Slitlamp examination showed slightly increased anterior chamber inflammation with rinsing in both the study group and placebo group. This observation was not confirmed by aqueous flare examination. No toxic effects of the products were found on histological evaluation. CONCLUSION: The combination mydriatic and anesthetic drug administered to pigmented rabbits as a single intracameral injection at volumes of 100 µL and 200 µL was well tolerated with no ocular adverse effects and no effect on the corneal endothelium.

Utility of 1% Tropicamide in Improving the Quality of Images for Tele-Screening of Diabetic Retinopathy in Patients with Dark Irides.

PURPOSE: To compare the quality of fundus photographs taken before and after instillation of one drop of tropicamide. METHODS: The 45º fundus photographs were taken with a non-mydriatic fundus camera in three conditions of the pupil; pre-mydriatic, 10 minutes after one drop of tropicamide, and fully dilated. Two photographs were taken in each condition; one centered on the macula and the other on the optic disc. Two vitreoretinal specialists graded the images. RESULTS: A total of 1768 fundus photographs of 149 diabetic patients with dark irides were included. There were more ungradable images (38.1% and 50.3%, graders 1 and 2, respectively) in the non-mydriatic state than partially- (4.6% and 11.5%) or fully-dilated (15.4% and 10.0%) conditions (p < 0.001, both graders). Partially and fully dilated states had similar rates of ungradable images (p = 0.56 and p = 0.54, graders 1 and 2, respectively). Test-retest reliability (repeatability) was 92.5% and 74.3% for the two graders, respectively. Inter-grader agreement was moderate (Kappa = 0.50). CONCLUSION: Non-mydriatic fundus photographs have a high rate of ungradable images in patients with dark irides. Instillation of only one drop of tropicamide improves the quality of fundus photographs, which is not furthered by adding more drops. This strategy can be used in tele-ophthalmology programs.

Early signal of diverted use of tropicamide eye drops in France.

AIMS: Tropicamide is a mydriatic drug used as eye-drops for diagnostic or therapeutic purposes. From 2013, a diverted use by intravenous route has been suspected in Eastern Europe in opioids users. To date, no signal of misuse has been identified in France. The aims of this study were to investigate any early signals of a diverted use of tropicamide eye drops and to collect information regarding motives for the misuse and tropicamide-induced effects. METHODS: Information was obtained at three levels: (1) at regional level (Midi-Pyrénées area), from reimbursement data and pharmacists' reports on suspicious requests; (2) at national level: from reimbursement data and prescriptions suggesting possible abuse from the OSIAP (Ordonnances Suspectes, Indicateur d'Abus Possible) survey; and (3) at international level: from VigiBase® reports and Web sources. Beta-blocker eye-drops were used as comparators. RESULTS: In France, in 2014-2015, 17 (0.91%, 95% CI [0.53-1.46%]) falsified prescriptions involving tropicamide were identified in the OSIAP survey (compared with 0%, 95% CI [0-0.19%] for beta-blockers). Moreover, 37 other suspicious prescriptions were presented in 2015 (notified in 2016). In Midi-Pyrénées, seven patients aged 35-49 were reimbursed for 19-45 vials of 10 ml, in a year. Since September 2014, the regional Addictovigilance Centre has received 91 notifications of suspicious requests to obtain tropicamide. In VigiBase® , two cases were identified but none in France. An increased interest in tropicamide-related Internet searches was observed from Russia and Ukraine. CONCLUSIONS: These results represent the first early warnings of a tropicamide diverted use in France. Tropicamide abusers would seek euphoria or hallucinations. The high doses involved in intravenous administration could lead to serious complications.

Effects of Mydrin eye-drops on central corneal thickness values in adult patients with myopia.

OBJECTIVE: This study aimed to evaluate the effect of Mydrin eye-drops on central corneal thickness values and investigate the duration of the effect. METHODS: In this prospective randomised self-controlled study, we enrolled 60 myopic patients (120 eyes) undergoing corneal laser refractive surgery. The central corneal thickness was measured before and one and four hours after administration of Mydrin eye-drops (major components are tropicamide and phenylephrine hydrochloride) using the Orbscan II anterior segment analysis system and a SP-2000P non-contact specular microscope, respectively. RESULTS: Using the Orbscan II system, the baseline central corneal thickness (545 ± 27 µm) was significantly lower than that at one hour after Mydrin eye-drop application (559 ± 31 µm; p < 0.001); it was comparable to that at four hours post-Mydrin eye-drop administration (544 ± 26 µm; p < 0.74). Measured by non-contact specular microscopy, the baseline central corneal thickness (508 ± 26 µm) was significantly lower than that at one hour after Mydrin eye-drop application (521 ± 29 µm; p < 0.001); it was comparable to that at four hours after Mydrin eye-drop administration (506 ± 24 µm; p = 0.62). A significant difference was observed in the central corneal thickness at one and four hours after Mydrin eye-drop application by both methods (p < 0.001). Bland-Altman plots showed agreement between the measurements by the two methods at different times. CONCLUSION: Central corneal thickness increases one hour after topical application of Mydrin eye-drops and is normalised at four hours following the administration of the drops. For patients scheduled to undergo excimer laser corneal refractive surgery, the central corneal thickness should be measured before or four hours after administration of Mydrin eye-drops.

Angle closure glaucoma in the Northern Ireland Diabetic Retinopathy Screening Programme.

PurposeTo ascertain the risk of angle closure glaucoma associated with mydriasis in the Northern Ireland Diabetic Retinopathy Screening Programme.MethodsA retrospective case note review was carried out, cross referencing hospital records with those of the screening programme, to identify episodes of angle closure glaucoma, which occurred within 14 days of a retinopathy screening episode involving pharmacological mydriasis.ResultsThree cases of angle closure following mydriasis for screening were identified. The incidence of angle closure within the screening programme was calculated to be 1 in 31 755 patients dilated or 0.75 patients per year.ConclusionAngle closure is a rare complication of mydriasis used in photographic screening for diabetic retinopathy. We advocate the provision of clear instructions to patients in screening programmes on when and how to access emergency ophthalmic care following dilation to prevent loss of vision in this rare event.