Intraocular pressure control with echothiophate iodide in children's eyes with glaucoma after cataract extraction.

PURPOSE: To report the intraocular pressure (IOP)-lowering ability and side-effect profile of echothiophate iodide (EI) in the control of glaucoma in aphakic and pseudophakic eyes of children. METHODS: The medical records of all aphakic and pseudophakic children treated with EI for IOP lowering after developing glaucoma were retrospectively reviewed. RESULTS: A total of 32 eyes of 21 children were included. Mean age at cataract removal was 3.9 months (range, 5 days-2.7 years). Mean age of glaucoma diagnosis was 3.2 years (range, 40 days-12 years). Mean duration from cataract removal and diagnosis of glaucoma was 2.9 years (range, 16 days-12 years). EI reduced IOP in 31 of 32 eyes. Mean baseline IOP (29.1 ± 5.3 mm Hg) dropped to 19.6 ± 6.7 mm Hg. Six eyes had IOP spikes that could not be controlled with other medications when commercial unavailability led to discontinuation of EI. Average duration of use was 3.5 years. Mean final IOP on an average of 2.2 medications was 16.9 ± 5.1 mm Hg 7.9 years following initial glaucoma diagnosis. Four eyes required surgery for uncontrolled IOP. Side-effects included transient redness (3/32 eyes), not necessitating discontinuation of EI. CONCLUSIONS: EI lowered IOP to within an acceptable range with no significant adverse events. In several patients it was the only pharmacologic agent that was successful.

Lowering of IOP by echothiophate iodide in pseudophakic eyes with glaucoma.

PURPOSE: We retrospectively investigated the intraocular pressure (IOP)-lowering effects of echothiophate iodide (EI) as adjunctive treatment for pseudophakic glaucoma patients who were receiving maximal medical therapy (MMT), including the newer class of medications, i.e., prostaglandin analogs, alpha-2 agonists, and topical carbonic anhydrase inhibitors. METHODS: The medical records of all pseudophakic glaucoma patients (24 eyes) under MMT who received supplementary EI 0.125% between January 2002 and December 2003 were reviewed. IOP data and number of medications before, during and after EI treatment were collected. RESULTS: Adding EI to MMT further reduced IOP in 23 of 24 eyes. Three eyes (12.5%) showed some lowering of IOP, but not enough to be considered controlled (IOP above the target pressure). The mean baseline IOP of 30.4 +/- 8.2 mmHg (median 29 mmHg) dropped at final follow-up (11.2 +/- 3.9 months) to 16.6 +/- 4.2 mmHg (median 17 mmHg, p < 0.0001) in all eyes that had showed effective pressure reduction upon the addition of EI. Their IOP rose to 27.7 +/- 8.0 mmHg (median 28 mmHg, p < 0.001) when EI was discontinued because of commercial non-availability. IOP reduction was > or =20% in 18 (75%) eyes and > or =30% (a mean decrease of 16.7 +/- 8.3mmHg) in 15 eyes (63%). Four eyes (16.6%) required a trabeculectomy despite EI supplement. Five eyes were re-challenged with EI when a small amount was released for sale: their IOP of 26.6 +/- 7.1 mmHg after the first EI discontinuation had dropped to 16.4 +/- 4.3 mmHg (p < 0.0001) and rose to 29.6 +/- 7.1 mmHg when EI was again discontinued. The recorded EI-associated side effects were increased miosis in all eyes and headache (8/24 patients), neither of which were reasons for discontinuation of the drug in any patient. CONCLUSION: EI substantially decreased the IOPs in pseudophakic glaucoma eyes receiving maximal medical therapy, including the newer class of medications. This drug may be the last resort for post-cataract advanced glaucoma patients and may obviate the need for filtering surgery among the very elderly.

Postoperative miotics for patients with infantile esotropia.

BACKGROUND AND OBJECTIVES: To examine the postoperative effect of echothiophate iodide in children who underwent surgery to congenital esotropia, and to find out whether it significantly reduced the residual esotropia. PATIENTS AND METHODS: Forty-one children who underwent surgery to correct congenital esotropia were randomly divided into a study group and a control group. The children in the treatment group received echothiophate iodide eyedrops once daily for 4 months, and all the children received dexamethasone eyedrops for 1 week after surgery. The strabismus angle was measured at 6 days, 6 months, and 12 months postoperatively for every patient. The measurements were compared in both groups using the paired Student's t test. RESULTS: The surgical procedure reduced the mean angle of esotropia by 32.4 prism diopters (PD) in the treatment group, and 38.8 PD in the control group. Six months after surgery, a mean decrease in the esotropia of 1.0 PD was observed in the treatment group, and a mean increase of 0.2 PD was observed in the control group. Twelve months postoperatively, the esotropia increased, by an average of 1.4 and 2.8 PD in the treatment and control groups, respectively. These differences were not statistically different (P > .05). CONCLUSION: Echothiophate iodide, given postoperatively for congenital esotropia, does not improve the surgical results during the first postoperative year.

Echothiophate iodide induced transient hyper- and hypothyroidism.

A case of hyper- and hypothyroidism induced by echothiophate iodide eye drops is presented. The thyroid dysfunction was due to excessive iodide intake from the eye drops.

Cholinergic toxicity resulting from ocular instillation of echothiophate iodide eye drops.

A patient developed a severe cholinergic syndrome from the use of echothiophate iodide ophthalmic drops, presented with profound muscle weakness and was initially given the diagnosis of myasthenia gravis. Red blood cell and serum cholinesterase levels were severely depressed and symptoms resolved spontaneously following discontinuation of the eye drops.

Intraocular pressure response to the replacement of pilocarpine or carbachol with echothiophate.

In 20 patients with open-angle glaucoma in aphakia or pseudophakia whose intraocular pressure had remained uncontrolled on their current medical therapy, the medication was changed from pilocarpine or carbachol to echothiophate iodide. In all, 12 patients (60%) showed a statistically significant improvement in pressure control, 7 (35%) showed no change, and 1 had higher pressure. One-third of the patients with improved intraocular-pressure control eventually required laser or incisional surgery after a mean of 23 months, whereas the remaining subjects were controlled for the duration of the follow-up, which averaged 26 months. Side effects encountered during echothiophate iodide treatment included ocular irritation, decreased vision, and one retinal detachment.

The management of post-keratoplasty glaucoma by trabeculectomy.

The results of 35 consecutive trabeculectomies in eyes developing medically uncontrollable glaucoma following penetrating keratoplasty are presented, with a mean follow-up of 3 years from the time of drainage surgery. Five eyes remained phakic until trabeculectomy was performed. Additional medical therapy was necessary to control the intraocular pressure in 32 eyes, which therefore were considered to have failed to be controlled by trabeculectomy and 90% of these failed within 6 months of filtration surgery. Despite additional medical therapy, in 17 eyes, further drainage surgery was required and 90% of this surgery took place within the first 14 months. Adverse prognostic factors were multiple grafts and synechiae closure of the drainage angle.

Drop attack in glaucoma. The Melbourne experience with topical miotics, adrenergic and neuronal blocking drops.

We have considered the effectiveness of miotics (pilocarpine 2% and ecothiopate iodide (Phospholine Iodide) 0.125 or 0.25%), adrenaline (Eppy/N 1%) or adrenaline precursors (dipivalyl epinephrine or dipivefrin hydrochloride (Propine) 0.1%) and neuronal blockers (timolol maleate (Timoptol) 0.5%) in 165 patients in the clinical situation. All drops were effective in lowering intraocular pressure with an average fall of 6.6 mmHg for timolol (160 eyes), 8.21 mmHg for pilocarpine (79 eyes), 5.77 mmHg for dipivalyl epinephrine (57 eyes), 7.23 mmHg for adrenaline (17 eyes) and 10.5 mmHg for ecothiopate iodide (16 eyes). In chronic simple open-angle glaucoma, ocular hypertension and pseudoexfoliative glaucoma, pilocarpine and timolol were almost equally effective while dipivalyl epinephrine and adrenaline were also effective, but more as additive therapy, though dipivalyl epinephrine may be useful on its own in ocular hypertension. In low-tension glaucoma timolol and dipivalyl epinephrine together seemed best, while in secondary glaucomas all were effective at times, but ecothiopate iodide was best in aphakic glaucoma and fluorometholone (FML Liquifilm) 0.1% was important in inflammatory glaucoma. Side effects were frequent with dipivalyl epinephrine and timolol, with respiratory disease a strong contraindication to timolol.

Cycloplegic refraction after echothiophate iodide.

Retinoscopy under cycloplegia using cyclopentolate (Cyclogyl) hydrochloride was performed on 18 patients (36 eyes) with partial or complete accommodative esodeviation, during and after treatment with echothiophate (Phospholine) iodide. Measurements were clinically comparable on both occasions, regardless of concentration of echothiophate, duration of administration, or interval from discontinuance until refraction. It appears to be unnecessary to discontinue echothiophate iodide in order to obtain reliable cycloplegic retinoscopic measurements.

[The influence of phospholine iodide on the squinting angle (author's transl)]. / Der Einfluss von Phospholinjodid auf den Schielwinkel.

The author discusses the results of phospholine iodide therapy on 112 children with convergent strabismus and comes to the conclusion that the possible complications of this therapy are not outweighed by its only very modest success.

[Comparative studies of the pressure-lowering effect of timolol and phospholine iodide (author's transl)]. / Vergleichsuntersuchungen mit Timolol und Phospholine-jodid bei Aphakieglaukom.

A comparative study of the intraocular pressure-lowering effects of timolol and phospholine iodide in cases of aphakic glaucoma was carried out. The authors compared the I.O.P.-lowering effect of these two drugs in 30 eyes (30 patients) with aphakic glaucoma over an eight-month observation period. The following was established after a statistical analysis of the material: 1. The I.O.P.-lowering effect of timolol in aphakic glaucoma cases is almost identical with the effect of the drug in cases of chronic open-angle glaucoma. 2. The administration of phospholine iodide in such cases leads to a stable I.O.P. regulation and it seems that this therapy should be preferred to treatment with timolol. 3. Timolol therapy in cases of aphakic glaucoma should be considered an enrichment of the known treatment methods. 4. The administration of timolol requires constant follow-up and if this is not possible therapy with pilocarpine or phospholine iodide should be preferred.

Controlled succinylcholine infusion in a patient receiving echothiophate eye drops.

A 69 year old man receiving echothiophate eye drops for glaucoma was given a controlled infusion of succinylcholine during elective surgery for incisional hernia. Neuromuscular blockade was assessed by the measurement of the force of contraction of the adductor pollicis muscle. Only 9.5 mg succinylcholine were required for tracheal intubation and 1.1 mg/min for maintenance. When the infusion was stopped, recovery of neuromuscular transmission was rapid and uneventful. Plasma cholinesterase activity was 62 per cent below normal, but the enzyme was qualitatively normal. Thus, muscle relaxation can be achieved safely with a succinylcholine infusion in patients with decreased plasma cholinesterase activity if neuromuscular function is closely monitored.

Serum cholinesterase, serum lipase, and serum amylase levels during long-term echothiophate iodide therapy.

Previous studies have found increased pancreatic intraductal pressures in dogs and the development of acute pancreatitis in humans after cholinergic stimulation. However, we did not find abnormally high levels of serum lipase or serum amylase in 44 patients with glaucoma using therapeutic doses of echothiophate iodide for intraocular pressure control on a long-term basis.

Miosis from echothiophate in patients with total oculomotor nerve paralysis from intracranial abnormalities.

Seven subjects with intracranial pathologic abnormalities received bilateral instillations of echothiophate. Six had unilateral third (oculomotor) nerve paralysis; one had unilateral third nerve paresis. All 14 eyes became miotic. Miosis was greater in the defective eye in three subjects, greater in the normal eye in two subjects, and equal in two subjects. The neurons originating in the ciliary ganglion and terminating on the sphincter pupillae muscle may exhibit spontaneous activity. Echothiophate, by preventing acetylcholine hydrolysis, may have allowed this transmitter to accumulate and to produce miosis. The amount of maximal miosis in the abnormal eye after bilateral instillation of echothiophate drops may vary from that in the normal eye. The causes of this variation include denervation supersensitivity of the sphincter pupillae muscle, partial paresis of the dilator pupillae muscle, and increased drug penetration in the abnormal eye.

Indications for medical treatment of ocular hypertension and the initial use of pilocarpine.

Ocular hypertension is defined. The decision to initiate treatment depends on the estimate of the benefit to injury ratio with a given treatment and the risk without treatment. Factors that determine our perception of the former are discussed. The key to the latter is the identification and evaluation of the ocular and systemic risk factors for the development of glaucomatous visual field loss. Discussion of these risk factors in the author's clinical practice is presented; overall, approximately 5% of his patients with ocular hypertension are treated. A review of his four-and-a-half year study on uniocular pilocarpine treatment in 59 ocular hypertensive patients is presented. The results suggest that one should be conservative in prescribing pilocarpine.