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Year : 1991  |  Volume : 39  |  Issue : 1  |  Page : 12-14

Achievement of surgically soft and safe eyes--a comparative study

Dept. of Ophthalmology Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Correspondence Address:
R N Sud
Dept. of Ophthalmology Dayanand Medical College and Hospital, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

PMID: 1909996

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With the advent of intra ocular lens implantation at the time of cataract extraction, especially by intracapsular method, it has become very important to prevent the loss of vitreous during surgery. This can be achieved by lowering the intraocular pressure by various methods. In order to find out the best method to achieve a soft & safe eye before surgery, a study was conducted on 90 patients, undergoing intracapsular cataract extraction. The patients were divided into 9 groups of 10 each, & different methods of lowering intraocular pressure were tried and results compared. It was observed that intravenous mannitol given preoperatively and pressure with mercury column together, formed the best combination to achieve the maximum tension lowering effect.

How to cite this article:
Sud R N, Loomba R. Achievement of surgically soft and safe eyes--a comparative study. Indian J Ophthalmol 1991;39:12-4

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Sud R N, Loomba R. Achievement of surgically soft and safe eyes--a comparative study. Indian J Ophthalmol [serial online] 1991 [cited 2023 Dec 11];39:12-4. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1991/39/1/12/24479

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  Introduction Top

A surgically soft & safe eye is essential during cataract operation, especially when intraocular lens implantation is to be done, and this can be achieved by pre-operative reduction of intraocular pressure. If the eye is soft before surgery the vitreous phase will remain concave after lens extraction and this will prevent its loss and help in quick and successful implantation of the intraocular lens.

Intraocular pressure can be lowered by the following methods:­

1. Use of medicines like carbonic anhydrase inhibitors, e.g. Diamox; or osmotic agents like oral glycerol, intravenous urea or mannitol.

2. Orbital decompression by (a) digital massage, (b) pressure with Super Pinky ball, (c) pressure with mercury column (d) Honan intraocular pressure reducer.

The present study was undertaken to find out the best method to achieve a soft & safe eye before intracapsular cataract extraction, especially for intraocular lens im­plantation.

  Material and methods Top

90 patients admitted to the hospital for cataract extrac­tion, were included in the study. A thorough general physical and ophthalmological (including slit lamp) ex­amination was done in each case. The patients were divided into 9 groups (A to I) of 10 each. In group A (control group), intraocular pressure was recorded 3 times i.e. before retrobulbar anaesthesia, after retrobul­bar anaesthesia & 3-5 minutes after digital massage. In each of the remaining 8 groups, B to I, the intraocular pressure was recorded by Schiotz tonometer and the initial reading was labelled as To, while the subsequent ones were labelled as T1, T2 & T3. Diamox 2 tablets (500 mg) were given 3 hours before surgery, to patients in groups B,C,D & E. 300 ml of 20% mannitol was given by intravenous drip in 30 minutes to patients in groups F,G,H & 1, and the patients were observed for any drip reaction or any other complication. Retrobulbar anaes­thesia was given as a mixture of 1 ml of 2% xylocaine & 1 ml of 5°/ bupivacaine (Marcaine) with a fine needle. Digital pressure was applied for 3-5 minutes after keep­ing a sterile pad over the eye, the pressure being released for 5 seconds after every minute. Mercury column pressure was applied in patients of groups D,E,H & I, by using a paediatric sphygmomanometer cuff which was connected with the mercury column. The off was tied around the eye to be operated, after .keeping 2-3 eye pads. A pressure of 40 mm Hg was applied for 15 minutes and during this procedure, blood pressure and pulse rate were monitored. Intracapsular cataract extraction was performed by cryo, Smith Indian technique or by intracapsular forceps.

  Observations Top

Out of 90 patients included in the study, 51 were males & 39 females. The age of ~patients varied from 45-75 years, with an average of 64 years.

[Table - 2] shows the total reduction of intraocular pressure in each group. The effect of Diamox on intraocular pressure, as observed by comparing groups A & C, was found to be statistically insignificant (P is greater than 0.05).

The effect of mannitol on intraocular pressure, as found out by comparing group A with G, was highly significant (P is less than 0.01).

To compare the tension lowering effect of digital mas­sage and pressure with mercury column, groups B & D, C & E, F & H and G & I were compared. Mean reduction in intraocular pressure, after pressure with mercury column, was more (8.8+0.3 mm Hg) as compared to that after digital massage (5.4 ± 0.3mm Hg) and the difference was statistically significant. There was no statis­tically significant difference in intraocular pressure before (9.3 ± 0.6 mm Hg) and after retrobulbar anaes­thesia (10.29 ± 0.5 mm Hg). In fact, in 45 patients (50%), there was a statistically significant increase in in­traocular pressure (2.8 mm Hg) after retrobulbar anaes­thesia.

  Discussion Top

The importance of preventing operative loss of vitreous during intracapsular cataract extraction, has been known for a long time, but it has gained more sig­nificance these days, because of the advent of in­traocular lens implantation surgery. It is generally believed that low intraocular pressure immediately before the anterior chamber is opened, reduces chan­ces of vitreous loss.

Becker [1]sub showed that Diamox in a dose of 500-1000 mg reduced intraocular pressure in normal and glaucomatous eyes, though the effect was much less in normal eyes. Aggarwal & Malik [2] reported a decrease in incidence of vitreous loss during cataract surgery, fol­lowing Diamox administration. On the other hand, Gartner [3]; Gundzik & Mayer [4]; and Robbins et al [5] did not find Diamox to be of any benefit in patients undergoing cataract surgery. In our study too, we did not find any statistically significant fall in intraocular pressure, follow­ing Diamox administration.

Hill [6]; Venturi & Barca [7]sub ; Jaffe [8]; and Engelstein [9] recom­mended the use of intravenous mannitol before cataract surgery. Hill [6] found a mean reduction of 7.2 mm Hg in intraocular pressure. In our study, the mean fall in in­traocular pressure, following mannitol administration (as seen in group G) was found to be 5.6 mm Hg, more as compared to the control group (group A) and this dif­ference was highly significant statistically (P is less than 0.01). Comparing the effect of mannitol with Diamox, on intraocular pressure, we found the effect of mannitol to be highly significant and that of Diamox insignificant.

Kirsch & Steinman [10], in a study on 100 cases, observed an average fall of 9.6 mm Hg in intraocular pressure following digital massage. Kirsch [11] in a further study, found a fall of 8.0 mm Hg after 2 1/2 minutes of massage. The value for the same was 7.2 mm Hg in studies conducted by Metz [12]. In our study, the value was 5.4 mm Hg., less than that of other workers.

Quist et a1 [13] used Honan's device after retrobulbar injection, at a pressure of 30 mm Hg for 5 minutes and noted an average fall of 6.5 mm Hg in intraocular pres­sure. Martin et al [14], following application of Honan's reducer for 40 minutes after retrobulbar anaesthesia, noted an average fall of 6.7 mm Hg in intraocular pres­sure. In the present study, the fall in intraocular pressure obtained with mercury column was 8.8 mrn Hg., slight more than that obtained by Quist et a1 [13] &Martinet al [14].

On comparison of groups B & D, C & E, F & H and G & I, in our study, it was observed that a fall in intraocular pressure, after pressure with mercury column (8.8 ± 0.3 mm Hg) was significantly higher than that after digital massage (5.4 ± 0.3 mm Hg). There are controversial reports on the role of retrobulbar anaesthesia in lowering~ intraocular pressure. Gifford [15]; and Kirsch & Steinman [10] noted a marked fall in intraocular pressure after retrobul­bar anaesthesia, whereas Metz [12]; Herschenfield & Breslin [16]; and Quist et a1 [13] failed to record any observ­able effect in lowering intraocular pressure. In contrast, Kim et a1 [17] and Jay et a1 [18] noted an increase in in­traocular pressure in most eyes after retrobulbar anaes­thesia.

In the end, it may be concluded that intravenous man­nitol produces a marked fall in intraocular pressure; and digital massage & pressure with mercury column both produce a significant fall in intraocular pressure but the effect was more marked after pressure with mercury column, especially after retrobulbar anaesthesia. It is further concluded that the ideal combination to reduce intraocular pressure before cataract surgery would be intravenous mannitol and pressure with mercury column.

  References Top

Becker, 8. 1954. Decrease in intraocular pressure in man by the carbonic anhydrase inhibitor, Diamox, preliminary report. Am.J. Ophthalmol.. 37:13­15.  Back to cited text no. 1
Aggarwai. L.P., and Malik, S.R.K. 1957. Diamox in cataract surgery. Ophthalmologica, 133: 153.  Back to cited text no. 2
Gartner, S. 1959. Methods of inducing anaesthesia & hypotony for cataract surgery. A.M.A. Arch. Ophthalmol., 61 : 50-54.  Back to cited text no. 3
Gundzik. J.D.. and Mayer. J. H.. 1963. The use of Diamox & retrobulbar injection to prevent vitreous loss. Am. J. Ophthalmol. 56 : 933-937.  Back to cited text no. 4
Robbins. R., Obstbaum, S.A., Best, M., and Galin, M.A. 1970. Influence of retrobulbar anaesthesia and acetazolamide. Brit. J. Ophthalmol. 54:801­804.  Back to cited text no. 5
Hill, K. 1964. Ocular osmotherapy with mannitol. Am.J. Ophthalmol. 58: 79-83.  Back to cited text no. 6
Venturi, G., and Barcal, L. 1979. Vitreous loss prevention in Documenta Ophthalmologica proceedings Series: First International Congress on Cataract Surgery. Francoise. J. : Maumenee• A.E.: and Estenle. I., Dr. W. Junk, Hague, Boston, London. pp. 321-330.  Back to cited text no. 7
Jaffe, N.S. 1979, Lens implantation with intracapsular cataract extraction­management of vitreous in symposium on cataracts. Transactions of the New Orleans Academy of Ophthalmology. The C.V. Mosby co.. St. Louis, pp. 216-226.  Back to cited text no. 8
Engelstein, J.M., 1983. Vitreous management in cataract surgery-Current options & problems. Grunc and Stratton Inc. Orlando, Florida, pp. 409-423.  Back to cited text no. 9
Kirsch. R.E.. and Steinman, W. 1955. Digital pressure, an important safeguard in cataract surgery. A.M.A. Arch. Ophthalmol. 54 : 697-703.  Back to cited text no. 10
Kirsch, R. E. 1957. Further studies on the use of digital pressure in cataract surgery. Arch. Ophthalmol. 58:641-646.  Back to cited text no. 11
Metz H.S.. 1967. Ocular tension and vitreous loss in cataract extraction. Am. J. Ophthalmol. 64: 309-312.  Back to cited text no. 12
Quist, L.H.: Stapleton, S.S.,; and PcPheson. Jr., S.D. 1983. Preoperative use of Honan's intraocular pressure reducer. Am. J. Ophthalmol. 95:536­538.  Back to cited text no. 13
Martin, N.F.; Stark, W.J., ; Maumenee, A.E.,; Bruner, W.E.: and Rosenblum. P 1982. Use of the Honan intraocular pressure reducer at the Wilmer Institute. Ophthalmic Surg. 13:101.  Back to cited text no. 14
Giffo,rd Jr., H. 1949. A study of the effect of retrobulbar anaesthesia on the ocular tension and vitreous pressure. Am.J. Ophthalmol. 32:1354-1359.  Back to cited text no. 15
Herschenfield• S.: and Breslin, C.W. 1981. Effect of retrobulbar anaes­thesia on ocular tension. Am.J. Ophthalmol. 92:759.  Back to cited text no. 16
Kim, J.H.; Lee, C.H.; and Kim S.D. 1985. Use of Honan's balloon for lowering the intrcocular pressure before cataract extraction. Afro-Asian J. Ophthal. 3:84-88.  Back to cited text no. 17
Jay, W.M.: Carter, H.; William, B.; and Green K. 1985. Effect of applying the Honan intraocular pressure reducer before cataract surgery. Am. J. Ophthalmol. 100:523-527.  Back to cited text no. 18


  [Table - 1], [Table - 2]


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