Intraocular pressure and pupil diameter in healthy cats anesthetized with isoflurane and pre-medicated with isolated acepromazine or in combination with tramadol / [Pressão intraocular e diâmetro pupilar em gatos saudáveis anestesiados com isoflurano e pré-medicados com acepromazina isolada ou em combinação com tramadol]

The objective of this study was to determine changes on intraocular pressure (IOP) and pupil diameter (PD) in healthy cats anesthetized with isoflurane, and premedicated with acepromazine alone or in combination with tramadol. Thirty cats were allocated in two groups (n=15/each) and were treated with acepromazine (AG) or acepromazine/tramadol (ATG). PD and IOP were assessed before and following 30 (PM1), and 40 minutes (PM2) of treatments. Anesthesia was induced with propofol, and IOP and DP were recorded (A10) at 10 minute intervals until the end of anesthesia (A40). IOP decreased in AG and ATG, when comparing baseline with PM1. IOP decreased only in AG, in comparisons between baseline and PM2. During anesthesia, IOP did not change within and between groups. Comparisons between baseline with those recorded at PM1 and 2 showed that PD increased in the ATG. During anesthesia, PD decreased significantly in AG and ATG. Both protocols maintained the IOP within the reference range to perform corneal or intraocular surgery in healthy cats but did not sustain pre-anesthetic pupil dilation observed in ATG.(AU)

O objetivo do presente artigo é determinar possíveis alterações na pressão intraocular (PIO) e no diâmetro pupilar (DP) em gatos saudáveis anestesiados com isoflurano e pré-medicados com acepromazina isolada ou em combinação com acepromazina/tramadol. Trinta gatos saudáveis foram distribuídos aleatoriamente em dois grupos (n=15/cada) e tratados com acepromazina (GA) ou acepromazina/tramadol (GAT). DP e PIO foram avaliadas antes (basal) e após 30 (PM1) e 40 minutos (PM2) dos tratamentos. A anestesia foi induzida com propofol, e a PIO e o DP foram registrados (A10) a cada 10 minutos até o final da anestesia com isoflurano (A40). Ao se compararem os valores obtidos no basal com PM1, a PIO diminuiu em GA e GAT; com PM2, a PIO reduziu apenas no GA. Durante a anestesia, a PIO não diferiu dentro e entre os grupos. Comparações entre os valores basais e os registrados em PM1 e em PM2 mostraram que a DP aumentou significativamente no GAT. Durante a anestesia, o DP diminuiu significativamente em GA e GAT. Ambos os protocolos mantêm a PIO dentro dos valores de referência para realizar cirurgias corneanas ou intraoculares em gatos saudáveis, mas não sustentam a dilatação pupilar pré-anestésica observada em GAT.(AU)

Comparision effects of solifenacin, darifenacin, propiverine on ocular parameters in eyes: A prospective study

ABSTRACT Objective To evaluate the effects of solifenacin, darifenacin, and propiverine on nasal-, subfoveal-, temporal choroidal thicknesses (NCT, SFCT, TCT), intraocular pressure (IOP) and pupil diameter (PD). Materials and Methods Patients with overactive bladder (OAB) diagnosed according to The International Continence Society were administered with solifenacin, darifenacin or propiverine on a daily basis between November 2017 and May 2018. NCT, SFCT, TCT, IOP, and PD of these patients were measured and compared as initial, fourth and twelfth weeks. Results A total of 165 patients (330 eyes) with OAB were evaluated. Solifenacin (n=140) significantly reduced IOP from 17.30±2.72 mmHg to 16.67±2.56 mmHg (p=0.006) and 16.57±2.41 mmHg (p=0.002), at the fourth and twelfth weeks, respectively. Darifenacin (n=110) significantly reduced NCT from 258.70±23.96 μm to 257.51±22.66 μm (p=0.002) and 255.36±19.69 μm (p=0.038), at the fourth and twelfth weeks, respectively. Propiverine (n=80) significantly increased PD from 4.04±0.48 mm to 4.08±0.44 mm (p=0.009) and 4.09±0.45 mm (p=0.001), at the fourth and twelfth weeks, respectively. Conclusion These findings can help to decide appropriate anticholinergic drug choice in OAB patients. We finally suggest further well-designed randomized prospective studies with a larger population to evaluate the anticholinergic-related complications in eyes.

Uso de retinógrafo portátil como ferramenta no rastreamento de retinopatia diabética / Use of a handheld fundus camera as a screening tool for diabetic retinopathy

Resumo Objetivo: Determinar a concordância do retinógrafo portátil Pictor Plus, na ausência de midríase, com a retinografia digital e avaliar a sua acurácia como método de rastreio da retinopatia diabética (RD). Métodos: Estudo transversal, mascarado para o observador, avaliando 100 olhos de 51 pacientes diabéticos. Foram realizadas retinografias com o Pictor Plus com e sem midríase, seguidos de retinografia convencional com o retinógrafo IMAGEnet por técnico treinado. As imagens obtidas foram analisadas por oftalmologista especialista em retina e classificadas normais, presença de edema macular diabético, retinopatia não proliferativa (inicial, moderada e grave) e retinopatia proliferativa, além de análise inviável. A concordância entre os resultados foi avaliada via coeficiente Kappa. As imagens foram agrupadas em normais e alteradas e estas em RD de alto risco e RD de baixo risco. Avaliou-se ainda a sensibilidade, especificidade, valores preditivos positivos e negativos, em relação à retinografia convencional. Resultados: Oitenta e nove por cento das imagens foram consideradas viáveis para classificação. Pouco mais de 31% dos olhos avaliados foram considerados como normais pelas três tecnologias. O exame com Pictor na ausência de midríase apresentou altos índices de sensibilidade e especificidade para a classificação normal (92,9% e 93,4%) e RD de alto risco (82,9% e 97,9%) e bons resultados para RD de baixo risco (75,0% e 87,0%). Conclusão: O Pictor Plus apresentou altos níveis de concordância com a retinografia digital ao discriminar exames normais de alterados e portadores de RD de baixo e alto risco. Foram verificadas ainda altas sensibilidade e especificidade desta ferramenta, se comparados à retinografia padrão.

Abstract Purpose: Determine the effectiveness of the use a portable handheld fundus camera as a screening method for diabetic retinopathy, compared to regular digital retinography. Methods: This is a cross-sectional, observer-masked study, evaluating 100 eyes of 51 diabetic patients undergoing a routine dilated retinography for diabetic retinopathy. Fundus images pre and post-dilation we captured by Pictor Plus (Volk Optical Inc., Mentor, USA), followed by routine digital retinography by IMAGEnet (Topcon Medical Systems, New Jersey, USA). All exams were performed by a trained technician on the same occasion. The images were analyzed and graded by a masked retina specialist and classified as normal, presence of diabetic macular edema, nonproliferative diabetic retinopathy (initial, moderate and severe) and proliferative diabetic retinopathy. The ungradable images were recorded and excluded from analyses. The agreement between results obtained by the three methods was evaluated via Kappa coefficient. Sensitivity, specificity, positive and negative predictive values in relation to IMAGEnet images were also determined. Results: Images were gradable in 89% of pre-dilation photos. Pictor Plus pre-dilation images had high sensitivity and specificity in identifying normal eyes (92.9% and 93.4%) and in vision-threatening DR (82.9% and 97.9%) both when compared to IMAGEnet results. Conclusion: Pictor can capture retinal images of sufficient quality to screen for DR with and without dilation. Single retinal images obtained using Pictor can identify eyes with vision-threatening DR with high sensitivity and specificity compared to routine IMAGEnet images.

Efficacy of preoperative nonsteroidal anti-inflammatory drug and the re-dilation technique in minimizing miosis after femtosecond laser in cataract surgery / Eficácia do AINE pré-operatório e da técnica de re-dilatação em minimizar a miose na cirurgia de catarata com laser de femtosegundo

ABSTRACT Purpose: To assess the efficacy of using a nonste­roidal anti-inflammatory drug preoperatively and of applying the re-dilation technique when necessary to minimize pupil size variation when comparing the degree of mydriasis before femtosecond laser pretreatment with that at the beginning of phacoemulsification. Methods: This retrospective study included patients who underwent cataract surgery using the LenSx (Alcon Laboratories, Inc., Fort Worth, TX). Our routine dilating regimen with flurbiprofen, tropicamide, and phenylephrine was used. The re-dilation technique was applied on eyes that manifested with a pupillary diameter that was smaller than the programmed capsulotomy diameter after laser pretreatment. The technique consists of overcoming pupillary contraction by instilling tropicamide and phenylephrine before phacoemulsification. Pupil size was assessed before femtosecond laser application and at the beginning of phacoemulsification. Results: Seventy-five eyes (70 patients) were included. Nine (12%) eyes underwent the re-dilation technique. There was no significant difference in mean pupillary diameter and mean pupillary area between the two studied surgical time points (p=0.412 and 0.437, respectively). The overall pupillary area constriction was 2.4 mm2. Immediately before opening the wounds for phacoemulsification, none of the eyes presented with a pupillary diameter <5 mm, and 61 (85.3%) eyes had a pupillary diameter >6 mm. Conclusion: Preoperative administration of nonsteroidal anti-inflammatory drug and the re-dilation technique resulted in no significant pupil size variation in eyes that were pretreated with the femtosecond laser, when comparing the measurements made before the laser application and at the beginning of phacoemulsification. This approach can avoid the need to proceed with cataract extraction with a constricted pupil.

RESUMO Objetivo: Avaliar a eficácia do uso de anti-inflamatório não-esteróide no pré-operatório e aplicação da técnica de re-dilatação quando necessária para minimizar a variação do tamanho pupilar ao comparar o grau de midríase antes do tra­tamento com laser de femtosegundo no início da facoemulsificação. Métodos: Esse estudo retrospectivo incluiu pacientes que foram submetidos à cirurgia de catarata usando o LenSx (Alcon Laboratories, Inc., Fort Worth, TX). Nosso regime de di­latação de rotina com flurbiprofeno, tropicamida e fenilefrina foi usado. A técnica de re-dilatação doi aplicada em olhos que se manifestaram com um diâmetro pupilar menor do que o diâmetro da capsulotomia programado após o pré-tratamento a laser. A técnica consiste em superar a contração pupilar pela instilação de tropicamida e fenilefrina antes da facoemulsificação. O tamanho pupilar foi avaliado antes da aplicação do laser de femtosegundo e no inicio da facoemulsificação. Resultados: Setenta e cinco olhos (70 pacientes) foram incluídos. Nove (12%) olhos foram submetidos à técnica de re-dilatação. Não houve diferença significativa no diâmetro pupilar médio e na área pupilar média entre os dois tempos cirúrgicos estudados (p=0,412 e 0,437, respectivamente). A constrição global da área pupilar foi de 2,4 mm2. Imediatamente antes de abrir as incisões para a facoemulsificação, nenhum dos olhos apresentava diâmetro pupilar <5 mm e 61 (85,3%) olhos apresentavam um diâmetro pupilar >6 mm. Conclusões: O administração pré-operatória de anti-inflamatório não-esteróide e da técnica de re-dilatação resultaram em uma variação significativa do tamanho pupilar em olhos que foram pré-tratados com laser de femtosegundo, comparando as medidas realizadas antes da aplicação do laser e no inicio da facoemulsificação. Essa abordagem pode evitar a necessidade de prosseguir com a extração da catarata com uma pupila contraída.

Acetylcholine chloride 1% usage for intraoperative cataract surgery miosis / Cloridrato de Acetilcolina 1% na obtenção da miose intraoperatória na cirurgia de catarata

Abstract Objective: To test the efficacy of Acetylcholine chloride use in obtaining intraoperative miosis on phacoemulsification cataract surgery. Methods: Patients with cataract diagnosis and elected for surgical phacoemulsification procedure were selected. All patients underwent conventional phacoemulsification procedure performed by a single surgeon and all patients had 0.2 ml of Acetylcholine chloride 1% irrigated in the anterior chamber at the end of the surgery. The pupillary diameter was measured immediately before the beginning of surgery, immediately before and two minutes after the use of acetylcholine chloride 1%. Results: A total of 30 eyes from 30 patients were included in the study. 18 were female, and mean age was of 69.5 years with a 7.2y standard deviation on the population study. The mean pupillary diameter immediately before the beginning of surgery was 7.5 mm with a standard deviation of 0.56 mm; the mean pupillary diameter immediately before the acetylcholine chloride 1% use (after the intraocular lens im-plantation) was 7.1 mm with a standard deviation of 0.57 mm. The mean pupillary diameter two minutes after the use of acetylcholine chloride 1% in the anterior chamber was 3.4 mm with standard deviation of 0.66 mm. The mean maximum action time of ACH chloride 1% was 64 seconds, with a standard deviation of 8 seconds. The mean intraocular pressure on the first postoperative day was 19.1 mmHg with a standard deviation of 2.45 mmHg. Conclusion: We conclude that acetylcholine chloride 1% is an important drug to obtaining intraoperative miosis in cataract surgery.

Resumo Objetivo: Demonstrar a eficácia do cloridrato de acetilcolina 1% na obtenção da miose intraoperatória na cirurgia de catarata pela técnica de facoemulsificação. Métodos: Pacientes com diagnóstico de catarata e indicação de cirurgia foram selecionados para participar do presente estudo. Todos os pacientes foram operados pela técnica de facoemulsificação convencional pelo mesmo cirurgião, todos foram submetidos à aplicação de 0,2 ml do cloridrato de acetilcolina 1% na câmara anterior ao final do procedimento cirúrgico. A medida do diâmetro pupilar foi realizada imediatamente antes do início da cirurgia, imediatamente antes do uso do cloridrato de acetilcolina 1% e após 2 minutos. Resultados: Foram estudados 30 olhos de 30 pacientes, destes, 18 eram do sexo feminino, a média de idade do estudo foi de 69,5 anos com desvio padrão de 7,2 anos. A média do diâmetro pupilar imediatamente antes do início da cirurgia foi 7,55 mm com desvio padrão de 0,56mm, a média do diâmetro pupilar imediatamente antes do uso do cloridrato de acetilcolina 1% (após implante da lente intraocular no saco capsular) foi 7,1mm com desvio padrão de 0,57mm. A média do diâmetro pupilar após 2 minutos da aplicação da acetilcolina na câmara anterior foi de 3,4 mm com desvio padrão de 0,66mm. O tempo médio de ação máxima do medicamento foi de 64 segundos, com desvio padrão de 8 segundos. A média da pressão intraocular no primeiro dia do pós-operatório foi de 19,1 mmHg com desvio padrão de 2,45mmHg. Conclusão: O estudo acima mostrou que a acetilcolina apresenta boa eficácia na obtenção de miose intraoperatória na cirurgia de facoemulsificação, permitindo uma maior facilidade na confecções das suturas corneanas ou corneo-escleral, reduzindo a incidência de sinéquias anteriores periféricas. Concluimos que o cloridrato de acetilcolina 1% é um importante medicamento na obtenção da miose intraoperatória na cirurgia de catarata.

The effect of intracameral epinephrine on pupil size during phacoemulsification and its postoperative effect on specular findings and macular thickness

ABSTRACT Objective: To evaluate pupillary size and vital signs following intraoperative intracameral adrenaline during phacoemulsification and postoperative effect of on co specular microscopy findings and macular thickness by OCT. Methods: A prospective interventional study carried out from December 2014 to December 2015 on 90 eyes. They were divided randomly into further 6 groups (15 each). The inclusion criteria consisted of no history of ocular pathologic conditions, trauma, previous ocular surgery, or recent ocular medication use. All patients were dilated preoperatively by phenylephrine 10% and operated under local peribulbar anesthesia. Then systemic monitoring regarding (pulse rate, blood pressure) and measurement of the horizontal pupil diameter by a caliper to the nearest 0.25mm pre and post intracameral adrenaline injection. Results: In our study there were great effect for intracameral epinephrine, with concentrations used, in dilatation and maintainance of papillary dilatation, The mean pre intracameral epinephrine was 4.53± 1.27 mm.The mean post epinephrine papillary diameter was 6.46± 1.00 mm. Three cases from group 1/10000 weren't dilated properly. Also three cases from group 1/9000 weren't dilated properly after intracameral epinephrine. Conclusion: Intracameral epinephrine even in higher concentrations is effective in papillary dilatation especially in cases with long duration and poorly dilated cases by usual topical mydriatics.

Effective pupil dilatation with a mixture of 0.75% tropicamide and 2.5% phenylephrine: A randomized controlled trial.

Purpose: To compare the efficacy in pupil dilatation between a mixture containing 0.75% tropicamide and 2.5% phenylephrine and the alternate application of 1% tropicamide and 10% phenylephrine eye drops. Material and Methods: Patients requiring pupil dilatation were randomized to receive one drop of the mixture every 10 min for four times or our standard application of one drop of 1% tropicamide alternating with one drop of 10% phenylephrine every 10 min for two cycles. Pupil size was measured under bright light with the pupil gauge before, and every 5 min after initial application for 40 min. Application of the drops was discontinued once the pupil diameter reached 7 mm. Blood pressure and pulse rate were monitored every 15 min. Results: Of 40 patients (age 57.3±10.9 years, range 35-70 years), 22 were randomized into the mixture group and 18 into the alternate drug group. Baseline pupil sizes were 1.7±0.5 mm in the mixture group and 1.8±0.4 mm in the alternate drug group. The pupils were successfully dilated to 7 mm within 40 min in 17 patients of the mixture group compared to seven patients in the alternate drug group (P=0.004, Log Rank test). The mean pupil sizes at 40 min were 6.6±0.8 and 6.0±0.9 mm in the mixture and alternate drug groups respectively (P=0.050, t-test). Blood pressure and pulse rate were stable and similar in both groups. Conclusions: The mixture of 0.75% tropicamide and 2.5% phenylephrine is superior to our standard application of 1% tropicamide alternating with 10% phenylephrine. It provides faster and more successful pupil dilatation within 40 min.

The Comparison of Mydriatic Effect Between Two Drugs of Different Mechanism

PURPOSE: To maximize effective use of mydriatic drugs through comparing the pupillary dilation effects between 1% tropicamide and 2.5% phenylephrine. METHODS: Fifty people requiring pupillary dilation were divided into 3 groups. Group 1 was treated with one drop of 1% tropicamide in the right eye and one drop of 2.5% phenylephrine in the left eye. Group 2 was treated twice during a 5-minute interval with 1% tropicamide in the right eye. Group 3 was treated twice during a 5-minute interval with 2.5% phenylephrine in the right eye. Groups 2 and 3 were treated with 2.5% phenylephrine and 1% tropicamide in the left eye, administered during a 5-minute interval. The pupillary size was measured in all groups for 40 minutes following eye drops administration. RESULTS: The mean patient age was 15.7 years. Group 1 included 10 patients, and groups 2 and 3 included 20 patients each. Eight patients in group 1 and 16 patients in group 2 developed a larger right pupil. Fourteen patients in group 3 developed a larger left pupil. CONCLUSIONS: Our study showed that 1% tropicamide, with its parasympathetic antagonistic mechanism of action, was more effective at inducing pupillary dilation than 2.5% phenylephrine, and the combination of 1% tropicamide and 2.5% phenylephrine was more effective than multiple drops of single eye drops.

A Pharmacologic Pupillary Test in the Diagnosis of Diabetic Autonomic Neuropathy

PURPOSE: To screen for diabetic autonomic neuropathy of the pupil using 0.5% apraclonidine and 0.1% pilocarpine and to evaluate the early diagnostic value of this pharmacologic pupillary test by assessing the relationship between pupillary and cardiovascular autonomic neuropathies. METHODS: A total of 22 diabetic patients were recruited. Baseline pupillary diameter (PD) and the difference in PD between the test eye and the control eye before and after instillation of apraclonidine and pilocarpine were measured. All patients also underwent cardiovascular autonomic function (CAF) testing. RESULTS: Baseline PD in room light correlated with duration of diabetes mellitus (DM, p=0.049) and the presence of DM retinopathy (DMR, p=0.022). Eleven patients (50%) had positive apraclonidine tests, and two patients had positive pilocarpine tests. The patients who had positive pilocarpine tests also had positive apraclonidine tests. Patients who had a positive pupillary test had a significantly higher rate of positive CAF tests (p=0.032). CONCLUSIONS: Pupillary autonomic neuropathy was related to the duration of diabetes and the degree of DMR. There was also a significant correlation between pupillary autonomic neuropathy and cardiovascular autonomic neuropathy (CAN). Also, sympathetic nerve dysfunction occurred prior to parasympathetic dysfunction in this study. A simple pharmacologic pupillary test can help manage complications in diabetic patients because patients with pupillary autonomic dysfunction have an increased risk of CAN.

Pupil dilation with intracameral lidocaine during phacoemulsification: Benefits for the patient and surgeon.

Topical and/or intracameral administration of anticholinergic and/or sympathomimetic mydriatic agents which are usually used for pupillary dilation during cataract surgery, have some disadvantages such as slow onset of dilation and adverse ocular and systemic effects. We evaluated intracameral injection of preservative-free 1% lidocaine without using any preoperative or intraoperative mydriatics to induce pupil dilation in 31 consecutive eyes scheduled for phacoemulsification cataract extraction and intraocular lens implantation. Pupil diameter was measured before and 90 sec after intracameral lidocaine injection. After intracameral lidocaine injection, the mean pupil diameter was significantly greater than the baseline measurement (P< 0.001). No additional mydriatics were needed up to the end of the operations. Intracameral preservative-free lidocaine 1% has a rapid and effective mydriasis that could be a safe alternative to topical and intracameral mydriatics in phacoemulsification.

Efeitos cardiovasculares e midriáticos da fenilefrina tópica a 2,5 e a 10,0 por cento em voluntários sadios / Cardiovascular and pupillary effects of topical ophthalmic 2.5 and 10.0 percent phenylephrine in healthy volunteers

OBJETIVO: Comparar os efeitos cardiovasculares e midriáticos da fenilefrina tópica nas concentrações de 2,5 e 10,0 por cento. MÉTODOS: Ensaio clínico do tipo caso controle, randomizado, com auto-emparelhamento. Foram monitoradas a freqüência cardíaca (FC), a pressão arterial (PA) e a midríase em voluntários sadios, com idade entre 18 e 45 anos, após a instilação da fenilefrina a 2,5 e a 10,0 por cento em duas ocasiões diferentes. RESULTADOS: A amostra foi constituída de 28 voluntários, sendo 17 do sexo masculino e 11 do sexo feminino, com a idade média de 26,5 anos. Não foi verificado nenhum padrão de mudanças com relação à freqüência cardíaca e à pressão arterial sistólica. Com relação à pressão arterial diastólica média dos indivíduos, não foi encontrada variação significativa após a instilação da fenilefrina a 2,5 por cento nos tempos de um, cinco, dez e 30 minutos, o que se revelou bem diferente quando do uso da fenilefrina a 10,0 por cento, com a qual houve aumento da pressão arterial diastólica média após cinco e dez minutos, e subseqüente queda após 30 minutos, porém sem significância estatística. A midríase foi maior com a fenilefrina a 10,0 por cento nos dois olhos, sendo a diferença estatisticamente significativa. CONCLUSÕES: Observou-se maior efeito midriático da fenilefrina a 10,0 por cento, quando comparada a 2,5 por cento, com significância estatística. Já com relação aos efeitos cardiovasculares não houve diferença estatística entre as duas concentrações.

PURPOSE: To compare the cardiovascular and mydriatic effects of 2.5 percent and 10.0 percent phenylephrine. METHODS: A case-control, randomized, crossover clinical trial study. We monitored heart rate (HR), blood pressure (BP) and mydriasis in healthy volunteers aged 18-45 years after the instillation of 2.5 percent and 10.0 percent phenylephrine in two different occasions. RESULTS: The sample comprised 28 healthy volunteers, 17 male and 11 female, with a mean age of 26.5 years. No changes in heart rate and systolic blood pressure were observed. No significant variation of the mean diastolic blood pressure was found after 1, 5, 10 and 30- minute instillation of 2.5 percent phenylephrine. However, with 10.0 percent phenylephrine, there was an increase in mean diastolic blood pressure after five and ten minutes, followed by a drop after 30 minutes, which was not statistically significant. Mydriasis was more marked in both eyes with a statistically significant difference after instillation of 10.0 percent phenylephrine. CONCLUSIONS: The mydriatic effect was greater with 10.0 percent phenylephrine than with 2.5 percent phenylephrine and the difference was statistically significant. No statistically significant difference was found in relation to cardiovascular effects in both phenylephrine concentrations.

Single dose of 1% tropicamide and 10% phenylephrine for pupil dilation.

OBJECTIVE: To compare the efficacy of pupil dilation between a single dose and three doses of 1% tropicamide and 10% phenylephrine for binocular indirect ophthalmoscopy. MATERIAL AND METHOD: A prospective randomized double-blind clinical controlled trial was conducted. All patients underwent the binocular indirect ophthalmoscopy and met the inclusion criteria were randomized into two groups using block randomization. Group A received a single dose of 1% tropicamide and 10% phenylephrine eye drops, and Group B received three doses of the same drugs. The primary outcome was the horizontal pupil diameter measured by slit-lamp biomicroscope (Haag-Streit model 900) before and at 10, 15, 20, 25 and 30 minutes after eye drop instillation. The clinical equivalence of the efficacy of pupil dilation between the two groups was defined as the difference of less than or equal to 1 mm (-1 mm to + 1 mm). RESULTS: Eighty patients (160 eyes) were randomized into 40 patients (80 eyes) in group A and 40 patients (80 eyes) in group B. The mean pupil sizes at baseline of group A were 3.51 +/- 0.63 mm in the right eye and 3.39 +/- 0.67 mm in the left eye. Those in group B were 3.61 +/- 0.67 mm in the right eye and 3.66 +/- 0.72 mm in the left eye. The mean pupil diameters at 30 minutes of group A were 7.34 +/- 0.51 mm in the right eye and 7.41 +/- 0.56 mm in the left eye, whereas those of group B were 7.49 +/- 0.45 mm in the right eye and 7.51 +/- 0.40 mm in the left eye. The mean difference of the pupil size between the two groups was 0.15 mm (p = 0.175) in the right eye and 0.l0 mm (p = 0.362) in the left eye. The 95% confidence intervals of the difference in pupil size were -0.36 to 0.07 mm in the right eye and -0.32 to 0.12 mm in the left eye. CONCLUSION: The 95% confidence interval of the difference in pupil size lay entirely within the range of equivalence. The single dose of 1% tropicamide and 10% phenylephrine was clinically equivalent to the three doses of the same drugs.

Congenital Horner's syndrome and the usefulness of the apraclonidine test in its diagnosis.

We present a seven-month-old baby with miosis of the left pupil, left hypochromia, mild ipsilateral ptosis, left hemifacial anhidrosis and asymmetrical facial flushing. A diagnosis of Horner's syndrome (HS) was presumed and was confirmed by instillation of apraclonidine eye drops. Miosis was reversed upon apraclonidine instillation. Magnetic resonance imaging of the head, neck and thorax and ultrasonography of the neck and abdomen did not reveal any pathological conditions. Although delivery-related brachial plexus injury is known as the most common cause of congenital HS, it should be investigated and should include neuroimaging of the sympathetic pathway, to exclude a serious underlying disease. As in our case, a specific etiology may not always be elicited. Pharmacological testing with apraclonidine may be a practical alternative to cocaine in the diagnosis of HS.

Ocular and cardiovascular autonomic function in diabetic patients with varying severity of retinopathy.

The study was conducted to assess the ocular and cardiovascular autonomic function in diabetic patients with varying severity of diabetic retinopathy. Ocular and cardiovascular autonomic function tests were performed in 30 patients with type 2 Diabetes Mellitus (10 in each group of proliferative retinopathy, non-proliferative retinopathy and no retinopathy) of more than 5 years duration and 10 normal controls. Ocular autonomic function tests were done by measuring pupil cycle time and denervation hypersensitivity with 0.125% pilocarpine and 0.5% phenylephrine. Cardiovascular autonomic function was measured by a battery of standard tests. Denervation hypersensitivity to 0.125% pilocarpine and to 0.5% phenylephrine and pupil cycle time showed statistically significant differences (P value < 0.001) between controls and patients with proliferative retinopathy (PDR) and also between no retinopathy and PDR (P < 0.001). Systemic autonomic function tests namely expiration--inspiration ratio, difference in heart rate, 30th beat and 15th beat ratio in head up tilt and difference in diastolic blood pressure in head up tilt test also showed significant difference (P < 0.01) between controls and all 3 groups of diabetics. There was statistically significant difference found in para-sympathetic ocular autonomic dysfunction between NPDR and controls. Ocular and systemic autonomic dysfunctions are related to the severity of diabetic retinopathy.

Comparative study of diclofenac sodium with adrenaline for prevention of intra operative miosis

To determined the efficacy of adrenaline, when used in irrigation solution for prevention of preoperative meioses during cataract surgery. It is a comparative study. Study was conducted at Ophthalmology unit of Abbasi Shaheed Hospital from January, 2004 to July 2004. One hundred [100] patients were selected, who had cataracts without associated problems. In 50 patients Diclofenac Sodium 1% was used pre operatively 4 times together with tropicanamide 1% eye drops. In other 50 patients only tropicanamide 1% eye drops were used to dilate the pupil. In these patients, adrenaline 1 ml [1:100] diluted in 500 ml of ringers solution was used during surgery. In all these extracapsular cataract extraction with IOL were performed. Pupils were studied at the start and at the end of surgery. Before surgery pupil size was 8mm approximately. At the end of surgery pupil size was 5.5 mm with diclofenac sodium and 6.5 mm in those cases where adrenaline added in irrigation solution. Delivery of the large lens through semidiluted pupils leads to some trauma to the sphincter pupillae which reacts by constriction even in presence of adrenaline and use of diclofenac sodium 1% eye drops. This type of pupillary constriction is less in presence of adrenaline in infusion irrigation solution during surgery

Randomized double-blind study of phenylephrine 2.5% vs 10% on pupillary dilation.

PURPOSE: To compare the efficacy of phenylephrine 2.5% versus 10% on pupillary dilation, and also compare their side-effects. METHOD: Patients at the Eye Clinic Srinagarind Hospital were randomized into two groups. Patients in group 1 received 1% tropicamide and 10% phenylephrine, whereas those in group 2 received 1% tropicamide and 2.5% phenylephrine. Pupil diameter, blood pressure and heart rate were measured before and after eyedrop instillation. RESULTS: Five hundred and sixty four patients were randomized into 293 patients (group 1) and 271 patients (group 2), using simple random sampling method. Mean pupil diameters before instillation in group 1 were 4.43 +/- 1.13 mm in the right eye and 4.31 +/- 0.95 mm in the left eye, whereas those in group 2 were 4.45 +/- 1.0 mm in the right eye and 4.32 +/- 0.92 mm in the left eye. After the instillation, the mean pupil diameters in group 1 were 7.58 +/- 0.96 mm in the right eye and 7.60 +/- 1.03 mm in the left eye, whereas those in group 2 were 7.17 +/- 1.04 mm in the right eye and 7.07 +/- 1.06 mm in the left eye. The difference was statistically significant (P < 0.05). There was no significant difference in mean systolic and diastolic blood pressure after instillation between the two groups. However, the mean heart rate after instillation in group 1 was greater than the value in group 2 with statistically significant difference. CONCLUSION: Pupillary dilation with 1% tropicamide and 10% phenylephrine is more effective than 1% tropicamide and 2.5% phenylephrine with statistically significant difference. After single dose instillation, there was no significant difference in the mean blood pressure between the two groups.

A pupila na fase crônica da doença de Chagas e reaçäo à pilocarpina e à fenilefrina / The pupil in patients with chronic Chagas' disease and reaction to pilocarpine and phenylephrine

To develop a method to analyse pupillary disturbances in patients with chronic Chagas disease in an endemic area, ten chagasic and ten normal subjects were matched according to sex, age and race. Pupillary diameter and area were determined using projection and topography techniques and compared between groups. Both pupils were visualised simultaneously. In each case three photographs were taken under standardised illumination. The first photo was obtained without medication, the second, 30 minutes after instillation of 0,1 per cent pilocarpine and the last 30 minutes after instillation of 3 per cent phenylephrine (60 minutes after pilocarpine). Pupils of chagasic patients had a statistically significant greater initial diameter and area, irregularity of the pupil border, greater percentual reduction in diameter and area after pilocarpine 0.1 per cent and greater percentual increase in diameter and area after 3 per cent phenylephrine eyedrops. The method developed for this study was considered satisfactory. The results suggest ocular autonomic nervous system disturbances in chagasic patients.

Midríase em cirurgias de catarata / Mydriasis in cataract surgery

Os autores apresentam sua experiência com midríase para cirurgias de catarata, induzida através de instilação única de colírios midriáticos associada com anestesia tópica e retro-bulbar. Os aspectos práticos da técnica são discutidos.

Pharmacodynamic effects of pilocarpine eye drop enhanced by decreasing its volume of instillation.

Previous studies have proved that as the volume of the drug solution instilled into the eye is decreased, the fraction of the dose absorbed into the ocular tissue is increased and the adverse drug reactions lowered. The present study investigated the acute effects of different drop volumes (10 microliters, 20 microliters, 40 microliters, and 80 microliters) of pilocarpine nitrate (2%) on pupil diameter, heart rate, and adverse reaction profile, in 12 healthy human volunteers. The drop volumes of 10 microliters and 20 microliters produced more miosis and less side effects than 40 microliters and 80 microliters drop volumes. This may be due to more penetration of the drug into the ocular tissue and less drainage into the nasolacrimal system.

Evaluation of antimuscarinic activity in human volunteers: a teaching aid in clinical pharmacology.

The antimuscarinic activity of oxyphenonium bromide, diphenhydramine hydrochloride and astemizole were evaluated in six volunteers. The parameters used were salivary secretion, heart rate and pupillary size. The results indicated that the changes in heart rate and pupillary size and measurements were not convenient parameters for class room demonstration. However, salivary secretion and dryness of mouth were found to be reliable parameters for measurement. It was concluded that simple procedures like evaluation of antimuscarinic activity could be introduced as teaching aids in clinical pharmacology for undergraduate students.