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| ARTICLES |
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| Year : 1978 | Volume
: 26
| Issue : 4 | Page : 33-37 |
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Phenylephrine-systemic effects from its topical use
RN Sud, SS Grewal
Dayanand Medical College, Ludhiana, India
Correspondence Address:
R N Sud
Dayanand Medical College, Ludhiana
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 437862 
How to cite this article:
Sud R N, Grewal S S. Phenylephrine-systemic effects from its topical use. Indian J Ophthalmol 1978;26:33-7 |
Phenylephrine is very frequently used in Ophthalmology for dilatation of the pupils specially for fundus examination and for breaking posterior synechiae. It is also a powerful vasoconstrictor drug. It is a sympathomimetic drug related to epinephrine, but is much more stable and produces a more lasting response. It causes mydriasis by acting on motor endplate of the muscle cell, and is an active process, not a passive process like the action of atropine. It has no effect on the ciliary muscle, so that mydriasis is achieved without any cycloplegia. When instilled into the conjunctival sac, it causes powerful mydriasis, in addition to vasoconstriction. It is not used in narrow angle glaucoma because of the danger of producing an acute attack of glaucoma.
It is usually considered to be safe. But certain reports have appeared in the literature suggesting definite side effects like subarachnoid haemorrhage after application of a cotton pack soaked in 10% phenylephrine to one of the eyes[15] and acute episodes of systemic hypertension after topical use of 10% phenylephrine hydrochloride.[21]
Samantary and Thomas (1975) reported a definite increase in blood pressure and slowing of heart rate after topical use of phenylephrine in all of their cases. We had not come across any untoward side effect from local use of this drug, inspite of its daily use in such a large number of our indoor and outdoor patients. In view of these reports of systemic effects from topical use of phenylephrine, we decided to assess the systemic effects of phenylephrine from its local use.
| Material and Methods | |  |
150 cases (100 normotensive and 50 hypertensive) attending the outpatients department of Ophthalmology of Dayanand Medical College and Hospital were studied. The age in normotensive group varied from 30 years to 86 years; and 30 to 73 years in hypertensive group.
One drop of 10% phenylephrine was instilled into the conjunctival sac of both eyes at 10 minutes interval thrice. Pulse and blood pressure were recorded before and 30 minutes after instillation.
A. Normotensive Group
Out of 100 cases, 60 were males and 40 were females. There was no change in blood pressure or pulse rate in 20 cases. Fall in pulse rate and rise in blood pressure was noted in 21 cases; rise in pulse rate associated with a fall in blood pressure was noted in 20 cases; fall in pulse rate without effect on blood pressure was noted in 8 cases; while a fall in pulse rate associated with fall in blood pressure was noted in 21 cases. Fall in blood pressure without any change in pulse rate was observed in 5 cases; while a rise in blood pressure without any change in pulse rate was seen in 5 cases. Increase in pulse rate without any effect on blood pressure was noted in 3 cases, and an increase in pulse rate associated with increase in blood pressure in 7 cases.
Maximum fall in pulse rate was 20/min, in males and 24/min. in females; while maximum rise in pulse rate was 16/min. in males and 14/min. in females.
Minimum fall in pulse rate was 2/min. in both males and females, while minimum rise was also 2/min. in both the sexes. A maximum fall of systolic blood pressure, 30 mm Hg in males and 20 mm Hg in females was noted; and a maximum rise of 20 mm Hg was noted both in males and females. There was a minimum fall of 4 mm Hg in males and 2 mm Hg in females; while a minimum rise of 2 mm Hg was noted in both males and females.
Similarly changes in diastolic pressure were noted. There was a maximum fall of diastolic blood pressure of 20 mm Hg in males and 14 mm Hg in females; and a maximum rise of 20 mm Hg in both the sexes. A maximum fall of 2 mm Hg in males and 4 mm Hg in females, and a minimum rise of 2 mm Hg in both males and females was noted.
B. Hypertensive Group
Out of a total of 50 cases, 23 were males and 27 females. There was no change in blood pressure or pulse rate in 9 cases; a fall in pulse rate associated with a rise in blood pressure was observed in 9 cases, while a rise in pulse rate associated with a fall in blood pressure in 4 cases. There was a fall in pulse rate without any change in blood pressure in 3 cases; and a fall in pulse rate associated with a fall in blood pressure in 9 cases. Fall in blood pressure without any change in pulse rate was observed in 6 cases; and a rise in blood pressure without any change in pulse rate in 3 cases. Increase in pulse rate without any change in blood pressure was observed in 2 cases; and increase in pulse rate associated with rise in blood pressure in 5 cases.
Maximum fall in pulse rate noted was 16/min. in both males and females; while a maximum rise in pulse rate noted was 12/min. and 6/min. in males and females respectively. Minimum fall and rise in pulse rate was the same in both males and females, i.e. 4/min. in males and 2/min. in females
A maximum fall of systolic blood pressure was 20 mm Hg in males and 40 mm Hg in females; and a maximum rise of 20 mm Hg in males and 24 mm Hg in females. A minimum fall of systolic blood pressure of 10 mm Hg in both the sexes was noted; while there was a minimum rise of 6 mm Hg in males and 4 mm Hg in females.
Changes were also noted in diastolic blood pressure. There was a maximum fall of diastolic blood pressure of 10 mm Hg in males and 12 mm Hg in females; and a maximum rise of 20 mm Hg in males and 12 mm Hg in females. Also noted was a minimum fall of 2 mm Hg in males and 6 mm Hg in females; while a minimum rise of 4 mm Hg in males and 10 mm Hg in females.
No untoward side reaction was noted in any case.
Changes in pulse rate, blood pressure, both systolic and diastolic, in males and females; in both normotensive and hypertensive groups are shown in [Table - 1],[Table - 2],[Table - 3],[Table - 4].
| Discussion | | |
Systemic reactions to topical use of epinephrine had been described by various authors[1],[8],[14],[20].
Heath[9] reported an increase of 50 mm Hg in systemic blood pressure in dog after application of 3 mg of phenylephrine powder on animal's cornea. Schepens[19] noted that application of phenylephrine to cornea alone caused nervousness, violent heart beat, severe occipital headache, nausea and vomiting.
Me Reynolds et al[15] reported a case of subarachnoid haemorrhage after application of a cotton pack soaked in 10% phenylephrine to one of the eyes. They found no rise in blood pressure in 94 cases and rise not more than 10 mm Hg in remaining six (out of 100 hypertensive patients). Lansche[14] described a case where the patient experienced diaphoresis, pallor and occipital headache with pressure of 220/120 mm Hg beginning 1 minute after instillation of the drop of phenylephrine immediately after applanation tonometry. Interestingly this patient had experienced a similar hypertensive episode after instillation of one drop of 1-epinephrine (Glaucon) 2% into each eye.
Wilensky and Woodward[21] described 3 cases of acute episode of systemic hypertension after topical use of 10% phenylephrine Hcl.
Samantary and Thomas[18] studied the systemic effects of topical phenylephrine in 30 normal and 30 hypertensive patients and found a definite increase in blood pressure both systolic and diastolic and slowing of heart rate in all the sixty patients, after the local use of the drug.
Our observations partly support those of Me Reynolds et al,[15] but not those of Samantary and Thomas.[15] Mc Reynolds et al[18] found no change in blood pressure in 94 out of 100 hypertensive patients; and in remaining six a rise not more than 10 mm Hg. We found no change in blood pressure or pulse rate in 20 of normotensive cases (20%) and 9 of hypertensive cases (18%); while a fall in pulse rate associated. with a rise in blood pressure was observed in 21 cases (21%) in normotensive patients and in 9 cases (18%) in hypertensive patients. Maximum rise of blood pressure in our cases was more than what was observed by Me Reynolds et a!. in their cases.
We also found cases showing a fall in pulse rate without an effect on blood pressure (8 cases, (16%) in normotensive group and 3 cases i.e. 6% in hypertensi ve group); a rise in pulse rate associated with a fall in blood pressure was noted in 10 cases (10%) of normotensive group and in 4 cases (8%) of hypertensive group; a fall in pulse rate associated with a fall in blood pressure was seen in 21 cases (21% of normotensive group and 9 cases (18%) of hypertensive group; fall in blood pressure without any change in pulse rate was observed in 5 cases (5%) of normotensive group and 6 cases (12%) of hypertensive group; increase in pulse rate without any change in blood pressure was seen in 3 cases (3%) of normotensive group and 3 cases (6%) of hypertensive group; and increase in pulse rate associated with increase in blood pressure in 7 cases (7%) of normotensive group and 5 cases (10%) of hypertensive group. None of these findings have been reported so far by any author.
Because of these variable results observed by us, we are inclined to agree with Wilensky and Woodward[21] that in certain individuals the instillation of 10% phenylephrine Hcl into conjunctival sac may be followed by a rise in blood pressure, but it is not possible to say whether rise in blood pressure represents overdose or an individual idiosyncracy unrelated to dosage.
Our observations are also different from those of Samantary and Thomas[18], who observed a rise in blood pressure and fall in pulse rate in all of their sixty cases, while we found a rise in blood pressure and fall in pulse rate in 21% of normotensive cases and 18% of hypertensive cases only.
But we have not been able to explain a fall in blood pressure or a rise in pulse rate observed in certain number of cases in both normotensive and hypertensive groups.
Thus we conclude that a rise in blood pressure followed by instillation into the conjunctival sac of phenylephrine 10% may be observed in certain individuals; but whether that is due to overdose or individual idiosyncracy unrelated to dosage or some other factor or factors is not clear; and we are of the view that it should be used in all the cases where indicated, keeping in mind the possibility of an idiosyncratic reaction occurring.
Unlike Schepens[19], Me Reynolds et al.[15] and Wilensky and Woodward; but like Samantary and Thomas[18], we did not find any untoward side effects like palpitation, sweating, trembling and fainting attacks.
| Summary | | |
150 patients (100 normotensive and 50 hypertensive) were studied for the effects of instillation of 10% phenylephrine into conjunctival sac, on blood pressure and pulse; and also for any other untoward side effects. It was concluded that while there was a rise in blood pressure and fall in pulse rate in some patients only, a large percentage of patients either showed no effect on blood pressure or pulse rate, or showed variable effects on blood pressure and pulse rate.
No untoward side effects were observed by us in any patient.
| References | | |
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| 18. | Samantary, S. and Thomas, A., 1975, 23, 16. |
| 19. | Schepens, C.L., 1951, Tr. Am. Acad. Ophth. Otolaryng., 55, 607. |
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| 21. | Wilensky, J.T. and Woodward, H.J., 1973, Amer. J. Ophthal., 76, 156. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4]
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