Indian Journal of Ophthalmology

: 1971  |  Volume : 19  |  Issue : 3  |  Page : 117--129

A study of effects of premedication with Pethidine, Largactil and Siquil used individually and in different combinations in cataract surgery

Brajananda Das 
 S. C. B. Medical College, Cuttack, India

Correspondence Address:
Brajananda Das
S. C. B. Medical College, Cuttack

How to cite this article:
Das B. A study of effects of premedication with Pethidine, Largactil and Siquil used individually and in different combinations in cataract surgery.Indian J Ophthalmol 1971;19:117-129

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Das B. A study of effects of premedication with Pethidine, Largactil and Siquil used individually and in different combinations in cataract surgery. Indian J Ophthalmol [serial online] 1971 [cited 2021 Apr 22 ];19:117-129
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The most common type of in­traocular surgery undertaken ex­tensively by an ophthalmic sur­geon is cataract extraction. Lack of co-operative response of the patient, nausea and vomiting both during and after operation have been responsible for a number of complications. The operation is easily accomplished and operative and postoperative complications are reduced to a minimum, if the patient is subjected to proper ana­esthesia and akinesia with suitable preoperative medication.

Many workers have discussed freely about choice of local or general anaesthesia in ocular sur­gery and the merits and demerits of each, but majority have opined in favour of local anaesthesia es­pecially for cataract surgery. In the United States, 90% of op­thalmologists use local anaesthesia (Atkinson [3] 1961), and in England, the figure appears to be 80% (Zorab, 1961,), whereas in India almost all cataract surgery is done under local, unless it is contra­indicated.

There has been an essential need for preoperative medication in order to achieve the relaxed state of the patient both mental and physical. More attention is being given now than before on use of sedatives like phenothia­zine derivatives and analgesics like pethidine as preoperative medicaments in cataract surgery in addition to barbiturates which though reported by different workers, requires proper evalua­tion. It was felt essential to have a deeper knowledge and a more comparative idea about the merits and demerits of different drugs used individually or in combina­tion. The present work has been carried out to study the effects of pethidine (meperidine hydrochlo­ride), Largactil (Chlorpromazine) and Siquil (triflupromazine) used individually and in different com­binations like pethidine with larg­actil and pethidine with siquil as preoperative medicaments in ca­taract surgery.

 Material and Method

The present work was carried out on 150 patients, who were ad­mitted to the S. C. B. Medical College Hospital, Cuttack for cata­ract extraction. Cases selected were usually elderly having senile mature cataract, although a very few had complicated or traumatic cataract or cataract with glau­coma. In all these cases, however, an attempt was made to deliver the lens either intracapsularly or extracapsularly.

Preliminary measures :­

On admission, the type of cata­ract, any gross systemic disorders and ocular defects other than cataract were noted. Pulse, res­piration, blood pressure (B.P.), intraocular pressure (I.O.P.) were also recorded. Prior to admission, routine examination of urine and conjunctival smear were made. Besides, an attempt was made to search for any focus of infection in the teeth, throat, accessory sinuses or lacrimal sacs and ap­propriate treatment given when sepsis was detected in such foci.

Pre-operative measures:­

In the evening previous to date of operation, the eye for operation was properly cleaned with anti­septic lotions and dressings as usual and a tablet of dial or Luminal was given to the patient at bed time.

On the morning of the opera­tion, after the usual preparations for surgery, when the patient was brought in the operation theatre, anethaine(1%) solution was in­stilled into the conjunctival sac three times, at 5 minute intervals.

For a comparative study, the patients were divided into 6 groups of 25 each, who were given intramuscular premeditation 20 to 30 minutes before operation as follows:­

1. Group I-Pethidine (100mg)

2. Group II-Largactil (50 mg)

3. Group III-Siquil (5 mg)

4. Group IV-Pethidine (50 mg) Largactil (25 mg)

5. Group V-Pethidine (50mg)

Siquil (2.5 mg)

6. Group VI-Treated as con­trol group did not get any premedication with the above drugs.

Next, ciliary block was effected by retrobulbar novocaine infiltra­tion as usual. Akinesia of orbicu­laris oculi was usually done by O'Brian's method. In a few cases, where the response was not ade­quate, van Lint method was ap­plied.

Now, prior to the operation, the patient's pulse, respiration, B. P. were recorded. I.O.P. was recorded twice i.e. once before giving retrobulbar injection and once after this, in order to note the drop of I.O.P. after the retro­bulbar injection.

Operative measures:­

After applying lid sutures and a superior rectus stitch, an upper corneal section was made with Graefe's knife in each case. In some cases, a broad peripheral iridectomy was done. The deli­very of lens was made either ex­tracapsularly or intracapsularly. The latter was usually attempted by Arruga's capsule frorceps ap­plied on the lower part of capsule or occasionally by the Smith Indian method of expression. In some cases, during delivery of lens, the capsule ruptured, which could not be recovered and the lens was extracted by expression and recorded as "failed intra­capsular". Vectis extraction was done in those cases, where indi­cated. In those cases, where pro­lapse of vitreous had occurred necessary toiletting was made. Before closing the eye, iris was reposited and some antibiotic drops or ointment put. In no case, however, corneal sutures had been given. Finally, both the eyes were covered with sterilised pads and bandage.

During operation, behaviour of the patient with regard to the following points were noted e.g. apprehension, relaxation, co-ope­ration, restlessness, delirium, drowsiness, pain during giving re­trobulbar injection, lid stitches or sup. rectus stitches and any other complaints like dryness of throat, tachycardia etc. No quantitative change in behaviour was recorded, the behaviour being studied clini­cally. Also complications like conjunctival haemorrhage, vitre­ous prolapse and intra-ocular haemorrhage if any, were noted.

Post operative measures-­

A record of the following was made in each case thrice (i.e. bet­ween 2 to 3 hours, 6 to 9 hours, and 24 hours after operation) viz. pulse, respiration, B.P., behavi­our responses as above, pain in the eye, sleep, nausea and vomit­ing, flatulence and retention of urine for which necessary treat­ment was given. At bed time, a hypnotic tablet was usually given to each patient.

Ocular complications like pro­lapse of iris and vitreous, non­formation of anterior chamber and intraocular haemorrage were also recorded for the first 3 days after the operation.


Mean results of pulse, respira­tion and B.P. on admission, after premeditation and before opera­tion and after operation have been shown in [Table 1],[Table 2],[Table 3] respectively. Mean results of I.O.P. on admission, after pre­medication and before and after retrobulbar infiltration have been shown in [Table 4].

Behaviour responses and com­plications during operation have been indicated in [Figure 1],[Figure 2] respectively.

Behaviour responses and com­plications after operation have been shown in [Table 6] respectively.


Out of 150 cases, 60% were males and 40% were females. The age group varied from 20 to 70 years. Maximum cases (80%) studied belonged to the age group varying from 40 to 70 years. In 33.3% cases; clinically anaemia was observed, which was not likely to have any effect on pre­medication and operation.

Now comparing the results ob­tained with regard to chances in pulse, respiration, B.P., I.O.P., type of cataract extraction, beha­viour response, operative and postoperative complications in the six different groups of patients. An idea about the efficacy of different types of premedication can be obtained.

Pulse and Blood Pressure:­

There has been an average in­crease of pulse rate just before operation in all the six groups, although it was minimum in the control group. It returned to about normal level in 2 to 3 hours after operation and showed slight increase again in 6 to 9 hours, which became normal 24 hours after operation [Table 1].

An average fall in B.P. both systolic and diastolic before opera­tion was detected in all the first 5 groups although most marked in groups IV and V whereas in the control group, a small rise of systolic pressure only was observ­ed. The B.P. in the first 5 groups reached practically normal level within 6 to 9 hours after opera­tion, whereas in Group VI, systo­lic pressure came to normal gra­dually within 24 hours after ope­ration [Table 2]. Again, a fall in systolic pressure of 10 to 30 mm Hg was observed in 100% cases in groups IV and V and 80%, 44% and 52% of cases in groups I, II and III respectively and 20% cases only in Group VI.

The findings on pulse and B.P., as stated above, in Groups III and V are similar to these reported by Agarwal, Sharma and Chandra [1] the slight increase in percentage of cases and decrease in duration of effect in the latter being quite likely due to intravenous admini­stration of drugs. Hanji [8] also found transient tachycardia in some patients due to Siquil, given intravenously as premedication.

Nutt and Wilson [16] have stated that the effect of pethidine and largactil on B.P. is not so marked in normotenasive patients and that the greater the degree of hypertension, the more precipit­ous the fall. In 2 out of their 80 cases, the preoperative systolic B.P. was over 250 mm Hg, which came down to between 70 to 90 mm Hg. as a result of largactil/ pethidine mixture given intrave­nously, slowly 15 minutes prior to operation, remained low for over 3 hours postoperatively and re­turned to preoperative level in 12 hours. In the present series 8 cases had quite high B.P. on ad­mission, but their B.P. was reduc­ed gradually by hypotensive drugs like serpasil, so that on the day of the operation it reached near about normal level. And as such, not a single case of serious hypo­tension was noticed as a result of premeditation with drugs, which were again administered intra­muscularly. But moderate hypo­tension of 10 to 30 mm Hg. was noticed in some cases as stated above. This shows the potentiat­ing action of phenothiazine group of drugs on pethidine, so far as lowering of B.P. is concerned, which again confirms the findings of Rolason and Hough [18] Moderate hypotension is certainly beneficial for cataract surgery, as it causes less bleeding and helps in reduc­ing I.O.P.

Severe hypotension requiring treatment in head-down position and administration of vasopressor drugs, was observed by Harly and Mishler [10] in 2 cases out of 100 cataract extractions and by Ingram and Armstrong [11] in 42 out of their series of 500 cases of intraocular surgery as a result of pethidine-largactil premedica­tion. In the present series, there has never been any occasion for coming across such risks, requir­ing undertaking of emergency measures as stated above. How­ever, sufficient care was taken in transportation of the patient in a perfect lying down position from the operation theatre to the ward and further the doses of different sedatives used for premedication, although constant for different groups of cases, were quite mode­rate and rather towards the low side than high. Thus the inci­dence of serious hypotension was nil.


The average increase of respi­ration rate as observed before operation in the first 5 groups is practically negligible [Table 3]. Ingram and Davison [12] have warn­ed about the possibility of respi­ratory depressant effect of pethi­dine, especially when given with other drugs intravenously, like promazine and phenergan etc. for causing heavy sedation for catar­act surgery, especially in cases with chronic bronchitis.

In the present series, not a single case of respiratory depres­sion was seen. There were al­together 5 patients in the series with pulmonary disease like bronchitis and asthma, of whom one belonged_ to Group IV and V each and 3 others to the control group. None of them also deve­loped any untoward respiratory complication during or after sur­gery. This is quite likely due to the fact that the dose was quite moderate and never large so that it exerted inappreciable effect on respiration. Moreover, when it is combined with phenothiazine group of drugs like largactil or siquil the latter increase the res­piratory rate depressed by pethi­dine. Besides, the route of ad­ministration of drugs used in the present series was intramuscular and not intravenous.

Intraocular pressure:­

From the mean result of I.O.P. [Table 4] it is seen that the effect of retrobulbar injection in redu­cing the I.O.P. is somewhat simi­lar in each group, i.e. a drop vary­ing from 3 to 4 mm Hg. but the reduction in I.O.P. is marked just before operation, when the pre­medication is effected with pethi­dine combined with either largac­til or siquil (Groups IV and V) i.e. 11 and 12 mm Hg respectively. Again, the fall of I.O.P. by 10 mm or more before operation was noted in majority of cases (92%) in group V and Group IV and in minimum number of cases (16%) in group II.

Agrwal et al [1] found that I.O.P. fell by an average of 7.5 mm Hg due to premeditation with chlor­promazine alone, 3 mm Hg due to curare alone and 9 mm Hg due to combination of chlorpromazine curare and acetazolamide and that in the chlorpromazine series some patients showed an average rise in tension of 11.7 mm Hg, where­as this did not occur in any of the other series. In the present work, the average fall in I.O.P. as ob­tained in Group II is similar to the above finding but in no case there was rise in I.O.P. The mark­ed lowering of I.O.P. due to pre­medication by combination of pethidine with largactil or siquil, as found in the present work has also been noted by Nutt and WiIson [16] and Kenny [14]

Behaviour responses during operation:­

These have been shown in [Figure 1] from which it is noted that good behaviour responses are observed in cases belonging to groups IV and V. In these groups, good re­laxation, cooperation, good sleep and calmness were observed in majority of cases, whereas the ad­verse effects like apprehension, restlessness, delirium, complaint of pain during giving stitches and other side complaints were ob­served in a minimum number of cases. Out of these 2 groups, effect of pethidine with siquil (Group V) was better. As regards premeditation with individual drugs, corresponding to groups I, II and III, there were variations in behaviour responses and it was observed that pethidine was supe­rior to largactil and siquil and between largactil and siquil, siquil appeared to be better. The effects of pethidine and siquil are found practically similar, so far as apprehension, relaxation, coopera­tion, restlessness and side com­plaints are concerned, but with pethidine, the patient feels more drowsy, does not become delirious and complains less of pain when stitches are applied. Largactil differs from siquil in that it causes more restlessness and dry­ness of throat.

In the control group, relaxation co-operation and drowsiness were found in least number of cases, whereas apprehension, restless­ness and pain during giving lid stitches etc. were well-marked. No case had delirium and side complaints were negligible.

Fishof [6] studying the effect of intravenous injection of meperi­dine hydrochloride (Demerol) alone in 108 cataract extractions in doses of 25, 50, 75 or 100 mg, obtained relaxation, semihypnosis and cooperation of the patients. but he, does not recommend the intravenous use of the drug indis­criminately, which should be con­fined to those displaying a tense and irritative psychomotor tem­perament. In the present series, meperidine hydrochloride (pethi­dine) alone was given in a dose of 100 mg. (Group I) and the effects with regard to above points were quite satisfactory.

Better effects on behaviour res­ponses due to combination of chloropromazine with pethidine or other drugs like curare, acetazola­mide etc. than due to chlorpromla­zine alone, have been noted by Byerley, Murray, Winter and Victols [3] Burn, Hopkin, Edwards and James [4] , Karkashian Hunt and Whishler [13] . Agarwal, Gupta and Malik [2] , which correspond to those seen in the present series i.e. in Groups II and IV. Of course, side complaints like dryness of mouth etc. were marked in cases receiv­ing largactil either alone or in combination with pethidine.

Agarwal et al [1] and Rehatgi [17] have found quite good effect of siquil on behaviour responses. The former noticed better effects when siquil was combined with pethi­dine and that side effects like dry­ness of mouth, tachhycardia etc. were maximum when it was given intravenously and minimum when given orally. In the present series, siquil was administered intra­muscularly and found to be quite effective as a potent tranquiliser and more so, when combined with pethidine. Side effects were seen in a very few cases also i.e. 12% in contradistinction to largactil premedication, where these were seen in 56% cases.

Complications during operation:­

Operative complications like conjunctival haemorrhage and prolapse of vitreous as obtained in percentage of cases have been shown in [Figure 2].

As to conjunctival haemorrhage, it occured in a maximum number of cases (40%) in the control group and least in Groups I, IV and V.

Vitreous prolapse occured maxi­mum (36%) in the control group and least in groups II, IV and V (12% in each).

In no case, however, there was intraocular haemorrhage.

Burn et al [4] found minimal con­junctival bleeding when premedi­cation was done with pethidine combined with chlorpromazine and promethazine. Agarwal et al [2] noted that the incidence of con­junctival bleeding and vitreous prolapse was less when chlorpro­mazine alone was given but least when it was combined with curare and acetazolamide which also lowered the I.O.P. to a marked extent, from which it is evident that more the reduction in I.O.P., lesser will be the incidence of vitreous prolapse.

In the present series as well, in­cidence of conjunctival bleeding was much less when pethidine was combined with largactil or siquil, than when the latter were used alone. With pethidine alone also, there was minimum bleed­ing. This shows that pethidine is helpful in this respect.

As to the incidence of vitreous prolapse, it was maximum in the control group, in which reduction of I.O.P. was least and was much less when combination of pethi­dine with largactil or siquil was given, in which the fall in I.O.P. was marked. Rehatgi [17] has re­ported that the incidence of vitre­ous prolapse was reduced to 1 % with premeditation with siquil 20 mg given intramuscularly, but in the present series, the result with siquil alone has not been encou­raging, as the incidence of vitre­ous prolapse has been 20%. Of course, the dose of siquil was only 5 mg. instead of 20 mg.

Behaviour responses in post-ope­rative period:­

These have been shown in [Table 5] and some have also been represented graphically [Figure 3].


Percentage of casess showing restlessness within 2 to 3 hours [Figure 3]A and 6 to 9 hours after operation has been quite low in the first 5 groups as compared to the control group.

None, however, was found rest­less 24 hours after operation. Restlessness was least marked in cases, who were given siquil either alone or in combination with pethidine, showing that it is somewhat more effective than lar­gactil or pethidine so far as sedation is concerned. Rohatgi [17] and Frank and Coyle [7] have also found good effect of siquil in this respect.


It was noted in only 2 cases (one each in Group II and III) who were, of course, extremely nervous in temperament and were also delirious during operation. Delirium continued in one of Group II up to 2 to 3 hrs and in the other of group III up to 6 to 9 hrs after operation.

Pain in Eye:­

It was complained of by many cases within 2 to 3 hours [Figure 3]B and by some within 6 to 9 hours after operation. None, how­ever, complained of the same 24 hours after operation. This com­plaint was made most in cases belonging to control group (96%) and least in cases in Group V (16%) within 2 to 3 hours after operation. This persisted upto 6 to 9 hours after operation in maximum number of cases in the . control group (80%) in a modera­tely high number in group II (52 0 %) and least in Groups I, III and IV i.e. 28%, 20% and 20% respectively, whereas no case be­longing to group V complained of the same then.


Best sleep was obtained in cases receiving pethidine. Largactil or siquil was not so effective in this respect. However, a combination of pethidine with either of these, especially with siquil (Gr. V) was quite satisfactory [Figure 3]C.

Nausea and Vomiting:­

Percentage of cases in the whole series showing these com­plications was quite negligible. This is quite likely due to the attention to the factors like use of pethidine and barbiturate rather than morphine, local anaethesia rather than general and early attention to post operative abdo­minal distension as observed by Hanno [9] (1965) at Wills Eye Hos­pital. In Gr. I 2 cases complained of nausea only within 2 to 3 hours and in Gr. IV, only one case had nausea and vomited twice within 6 to 9 hours after operation and in control group, out of 2 cases one complained of only nausea for 2 to 3 hours after operation and the other nausea throughout for the day and vomited once in the morning 24 hours after operation. No case in any of the other groups had either nausea or vomi­ting [Table 5]. Thus in this respect largactil has been found superior to siquil, which corrabo­rates with the observations of Hanji [8] (1963).


It was noted in moderate num­ber of cases within 6 to 9 hours after operation in all the groups except Group V and most marked in group I and control group (32% each) [Figure 3]D Only in one case in Gr. I, it was noted 24 hours after operation.

Harley and Mishler [10] have found from their study on 200 cataract cases that abdominal distension was uncommon and they believe that since the patients are allow­ed to sit up immediately post­operatively and allowed to turn on the unoperated side, this complication is markedly reduced. If this be so, the cause of increased inci­dence of abdominal distension in the present series is obvious, since cases in these series were not al­lowed to sit up for 3 to 4 days after operation.

Retention of urine:­

Agarwal et al [2] did not find post-operative retention of urine in any of their cataract extraction cases receiving chlorpromazine alone, acetazolamide alone and combination of acetazolamide, curare and chlopromazine, except in very few cases receiving curare alone. But in the present series, quite a large number developed this complication usually within 6 to 9 hours after operation, most marked in control group and in those receiving pethidine (i.e. Gr. I) [Figure 3]E. With siquil alone, this complication was least mark­ed; in no case, however, it was seen 24 hours after operation.

Post-Operative Complications:­

These have been shown in [Table 6] from which it is seen that incidence of prolapse of iris and vitreous and non-formation of anterior chamber and intraocular haemorrhage in form of hyp­haema, although low was more marked in Gr. I, II, III and in the control group and least in Group No. IV and V: This occured in some cases, who showed post-ope­rative restlessness, vomiting and retention of urine. Of course, post-operative complications as seen after 2nd day of operation need not be attributed to the effects of pre-medication, which certainly never last for more then 24 hours, but in certain cases the latter may be indirectly respon­sible, as the complications seen on 2nd day of operation may conti­nue to be present the next day.

 Summary and Conclussions

1. Study of pre-operative medication in cataract surgery under local anaesthesia has been made on 150 cases, who were divided into 6 groups of 25 each. The first three received pethidine, largactil and siquil alone, the fourth one, pethidine and largactil and the fifth, pethidine and siquil. Group VI was treated as control.

2. The effects of these preme­dicaments on pulse, respiration, blood pressure, intraocular pres­sure, behaviour responses of the patients and operative and post­ operative complications have been studied.

3. With regard to premedica­tion, the effects of combination of pethidine with largactil or siquil were found to be better than indi­vidual drugs. Finally, between two types of combined premedita­tion, pethidine with siquil was found superior to pethidine with largactil.

I am grateful to Dr. M. C. Misra, D. O. M. S. (London), Retired Professor and Head of the Department of Oph­thalmology, S.C.B. Medical College Cuttack, who was my guide.


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