Methylcellulose and Lens Implantation.br J Ophthalmol-1983-Fechner-259-63
6
8/19/2019 Methylcellulose and Lens Implantation.br J Ophthalmol-1983-Fechner-259-63 http://slidepdf.com/reader/full/methylcellulose-and-lens-implantationbr-j-ophthalmol-1983-fechner-259-63 1/6 British Journal of Ophthalmology, 1983, 67, 259-263 Methylcellulose and lens implantation PAUL U. FECHNER AND MARTIN U. FECHNER From the Department of Ophthalmology, RobertKoch Hospital, 3007 Hannover-Gehrden, West Germany SUMMARY Methylcellulose has beenused since 1976 to preventdamage to the corneal endothelium duringoperations for implantation of intraocularlenses. Originally one drop of a 1 solution was placed on the artificial lens just before its insertion. Later the anterior chamber was completely filled with a 2 solution of methylcellulose before implantation. In this way it is possible to maintaina space between the comea and iriseven if vitreous pressure is present and to operate without risk to the comeal endothelium. This paper demonstrates the safety ofthe intraocular u se of methylcellulose on the basis of over 400 operations. The substance is cheap, universally available, and can be easily prepared for intraocular use. The past decade has seen the development of the endothelial specular microscope. 2 This instrument led to the realisation that corneal endothelial cells are almost entirely incapable of celldivision, and that healing of corneal endothelial wounds can take place only by means of enlargement and sliding of the remaining endothelial cells.3 The recognition of this fact fostered a new thinking in ophthalmic microsurgery. Utmost care withrespect to the endothelium of the cornea became the law, particularly when a cataract operation was combined with the implantation of an artificial lens. Rules developed to whichophthalmic surgeonsshould strictly adhere4: as little bending of the cornea as possible5; as little irrigation by an irrigating solution as physiological as possible67; absolute avoidance of contact between instruments and the endothelium, and, most important, between the artificial lens and the endothelium.89 To lessen the danger of contactbetween the intra- ocular lens and the cornea Binkhorst et al. recom- mended the air cushiontechnique. 0 Air tends to leave the anterior chamber quickly, however, and to prevent that happening Healon (sodium hyaluronic acid 1 ) was recently introduced The senior author has successfully used methylcellulose since 1976 to prevent the rubbing of the intraocular lens against the endothelium, and because his experience with this substance was extremely favourable he did not change to Healon. Thispaper demonstrates the safety of the intra- ocular use of methylcellulose. In particular, data are Correspondence to Dr P. U. Fechner, Schmiedest. 41, 3000 Hannover, West Gernany. presented to show that if there is a methylcellulose- related post-surgical increase in intraocular pressure it is not clinically significant. Material and methods CHEMISTRY OF METHYLCELLULOSE Methylcellulose used for intraocular surgery is a highly purified brand of hydroxypropyl methylcellu- lose. The hydroxypropyl and methyl groups replacing hydrogen groupsincrease the hydrophilicity of the compound. The cellulose polymer is widely found in nature as a structural substance-e.g., in the cells of wood and cotton. The basic molecule is D-glucose. Two monomers of glucosecombine to form cello- biose, which differs fromdextrose only in the wa y the 2 monomers are stereochemically connected: in cellobiose the bonding is beta-glycosidic, in dextrose alpha-glycosidic. The human enzyme system can hydrolyse alpha-glycosidic bonds but supposedly is incapable of breaking cellobiose bonding(and there- fore methylcellulose), at least in the intestine and in larger quantities. What happens to the minute amount of methylcellulose which may remain in the body after intraocular application is uncertain, but the question seems to be without clinical significance. PREPARATION F OR INTRAOCULAR USE A description is given below of the preparation of a 2 solution of methylcellulose suitable for intra- ocular use. There are a number of essential points to be considered. a) The methylcellulose must be of the high- est purity. Methocel E 4 M Premium' of Dow 259 group.bmj.com on April 10, 2015 - Published by http://bjo.bmj.com/ Downloaded from
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Transcript of Methylcellulose and Lens Implantation.br J Ophthalmol-1983-Fechner-259-63
8/19/2019 Methylcellulose and Lens Implantation.br J Ophthalmol-1983-Fechner-259-63
http://slidepdf.com/reader/full/methylcellulose-and-lens-implantationbr-j-ophthalmol-1983-fechner-259-63 1/6
B r i t i s hJ o u r n a lo f O p h t h a l m o l o g y ,1 9 8 3 ,6 7 ,2 5 9 - 2 6 3
M e t h y l c e l l u l o s ea n d l e n si m p l a n t a t i o n
PAUL U. FECHNER AND MARTIN U . FECHNER
F r o m t h eD e p a r t m e n to f O p h t h a l m o l o g y ,R o b e r tK o c h H o s p i t a l ,3 0 0 7H a n n o v e r - G e h r d e n ,W e s tG e r m a n y
SUMMARY M e t h y l c e l l u l o s eh a s b e e nu s e ds i n c e1 9 7 6t o p r e v e n td a m a g et o t h e c o r n e a le n d o t h e l i u md u r i n go p e r a t i o n sf o ri m p l a n t a t i o no f i n t r a o c u l a rl e n s e s .O r i g i n a l l yo n e d r o p o f a 1 s o l u t i o nwa s
p l a c e don t h e a r t i f i c i a ll e n sj u s tb e f o r e i t si n s e r t i o n .L a t e r t h e a n t e r i o rc h a m b e rw a s c o m p l e t e l yf i l l e dw i t h a 2 s o l u t i o no f m e t h y l c e l l u l o s eb e f o r e i m p l a n t a t i o n .I n t h i sway i t i s p o s s i b l et o
m a i n t a i na space b e t w e e nt h e c o m e a a n d i r i se v e n i f v i t r e o u sp r e s s u r e i s p r e s e n t a n d t o o p e r a t ew i t h o u tr i s kt o t h e c o m e a le n d o t h e l i u m .T h i sp a p e r d e m o n s t r a t e st h e s a f e t yo f t h e i n t r a o c u l a ru se
o f m e t h y l c e l l u l o s eon t h e b a s i so f over 4 0 0 o p e r a t i o n s .T h e s u b s t a n c ei s c h e a p , u n i v e r s a l l ya v a i l a b l e ,a n d c a n b e e a s i l yp r e p a r e df o r i n t r a o c u l a ru s e .
T h e p a s t d e c a d e h a s s e e n t h ed e v e l o p m e n to f t h ee n d o t h e l i a ls p e c u l a rm i c r o s c o p e . 2T h i s i n s t ru m e n tl e dt o t h er e a l i s a t i o nt h a tc o r n e a le n d o t h e l i a lc e l l sa r ea l m o s te n t i r e l yi n c a p a b l eo f c e l ld i v i s i o n ,a n d t h a th e a l i n go f c o r n e a le n d o t h e l i a lw o u n d sc a n t a k ep l a c eo n l y b y m e a n s o f e n l a r g e m e n ta n d s l i d i n go f t h er e m a i n i n ge n d o t h e l i a lc e l l s . 3
T h er e c o g n i t i o no ft h i sf a c tf o s t e r e da new t h i n k i n gi no p h t h a l m i cm i c r o s u r g e r y .U t m o s tc a r e w i t hr e s p e c tt o
t h ee n d o t h e l i u mo f t h ec o r n e ab e c a m et h el a w ,
p a r t i c u l a r l yw h e na c a t a r a c to p e r a t i o nw a sc o m b i n e dw i t h t h e i m p l a n t a t i o no f a n a r t i f i c i a ll e n s .R u l e sd e v e l o p e dt o w h i c h o p h t h a l m i cs u r g e o n s s h o u l ds t r i c t l ya d h e r e 4 :a s l i t t l eb e n d i n go f t h ec o r n e a a sp o s s i b l e 5 ;a s l i t t l ei r r i g a t i o nb y a n i r r i g a t i n gs o l u t i o na s p h y s i o l o g i c a la sp o s s i b l e 6 7 ;a b s o l u t ea v o i d a n c eo fc o n t a c t b e t w e e ni n s t r u m e n t sa n d t h ee n d o t h e l i u m ,a n d , m o s ti m p o r t a n t ,b e t w e e nt h ea r t i f i c i a ll e n sa n dt h e e n d o t h e l i u m . 8 9
T o l e s s e nt h ed a n g e ro f c o n t a c tb e t w e e nt h e i n t r a -o c u l a r l e n sa n d t h ec o r n e aB i n k h o r s te t a l . r e c o m -m e n d e dt h ea i r c u s h i o nt e c h n i q u e . 0A i r t e n d s t ol e a v e t h ea n t e r i o rc h a m b e rq u i c k l y ,h o w e v e r ,a n d t op r e v e n t t h a th a p p e n i n gH e a l o n ( s o d i u mh y a l u r o n i ca c i d1 ) w a sr e c e n t l yi n t r o d u c e dT h es e n i o ra u t h o rh a s s u c c e s s f u l l yu s e d m e t h y l c e l l u l o s es i n c e1 9 7 6 t op r e v e n tt h e r u b b i n go f t h e i n t r a o c u l a rl e n sa g a i n s tt h ee n d o t h e l i u m ,a n d b e c a u s eh i se x p e r i e n c ew i t ht h i ss u b s t a n c ew a s e x t r e m e l yf a v o u r a b l eh e d i d n o tc h a n g et o H e a l o n .
T h i s p a p e r d e m o n s t r a t e st h e s a f e t yo f t h ei n t r a -o c u l a ru s e o f m e t h y l c e l l u l o s e .I n p a r t i c u l a r ,d a t a a r eC o r r e s p o n d e n c et o D r P . U . F e c h n e r , S c h m i e d e s t .4 1 , 3 0 0 0H a n n o v e r ,W e s tG e r n a n y .
p r e s e n t e dt o s h o wt h a ti f t h e r ei s a m e t h y l c e l l u l o s e -r e l a t e dp o s t - s u r g i c a li n c r e a s ei n i n t r a o c u l a rp r e s s u r ei t i sn o t c l i n i c a l l ys i g n i f i c a n t .
M a t e r i a la n d m e t h o d s
CHEMISTRY OF METHYLCELLULOSE
M e t h y l c e l l u l o s eu s e d f o r i n t r a o c u l a rs u r g e r y i s ah i g h l yp u r i f i e db r a n d o f h y d r o x y p r o p y lm e t h y l c e l l u -l o s e .T h eh y d r o x y p r o p y la n d m e t h y lg r o u p sr e p l a c i n gh y d r o g e ng r o u p si n c r e a s et h eh y d r o p h i l i c i t yo f t h ec o m p o u n d .T h ec e l l u l o s ep o l y m e ri sw i d e l yf o u n di nn a t u r e a s a s t r u c t u r a ls u b s t a n c e - e . g . ,i n t h ec e l l so fwood a n d c o t t o n .T h e b a s i cm o l e c u l ei s D - g l u c o s e .T wo monomers o f g l u c o s ec o m b i n et o f o r m c e l l o -b i o s e ,w h i c hd i f f e r sf r o md e x t r o s eo n l yi nt h ewa y t h e2 monomers a r e s t e r e o c h e m i c a l l yc o n n e c t e d : i nc e l l o b i o s et h eb o n d i n gi s b e t a - g l y c o s i d i c ,i nd e x t r o s ea l p h a - g l y c o s i d i c .T h e h u m a n e n z y m es y s t e m c a nh y d r o l y s ea l p h a - g l y c o s i d i cb o n d s b u t s u p p o s e d l yi si n c a p a b l eo f b r ea k i ngc e l l o b i o s eb o n d i n g( a n d t h e r e -f o r em e t h y l c e l l u l o s e ) ,a t l e a s ti n t h ei n t e s t i n ea n d i nl a r g e rq u a n t i t i e s .W h a t h a p p e n st ot h em i n u t ea m o u n t
o f m e t h y l c e l l u l o s ew h i c hm a y r e m a i ni n t h eb o d ya f t e ri n t r a o c u l a ra p p l i c a t i o ni s u n c e r t a i n ,b u t t h eq u e s t i o ns e e m st o b e w i t h o u tc l i n i c a ls i g n i f i c a n c e .
PREPARATION F OR INTRAOCULAR USE
A d e s c r i p t i o ni s g i v e nb e l o wo f t h ep r e p a r a t i o no f a2 s o l u t i o no f m e t h y l c e l l u l o s es u i t a b l ef o r i n t r a -o c u l a ru s e .T h e r ea r e a n u m b e ro f e s s e n t i a lp o i n t st ob e c o n s i d e r e d .
a ) Th e m e t h y l c e l l u l o s em u s t b e o f t h e h i g h -e s t p u r i t y .M e t h o c e lE 4 M P r e m i u m 'o f D o w
2 5 9
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P a u l U . F e c h n e ra n d M a r t i nU . F e c h n e r
C h e m i c a lC o r p o r a t i o ni s r e c o m m e n d e df o r u s e . b ) A p h y s i o l o g i c a ls o l v e n ts h o u l db e u s e d .T h e
f o l l o w i n gs o l v e n t sa r es u i t a b l e :B a l a n c e ds a l ts o l u t i o n( B S S ) A l c o n ) ,R i n g e r ss o l u t i o n ,R i n g e r sl a c t a t e
s o l u t i o n ,o r
e q u i v a l e n t s . c ) A n t i s e p t i cc o m p o u n d sl i k e b e n z a l k o n i u m ,c h l o r b u t a n o l ,t h i m e r o s a l ,a n d o t h e r sa r ed a m a g i n gt ot h ee n d o t h e l i u ma n d m u s tn o t b e u s e d .T h es o l u t i o nt h e r e f o r eh a st ob e s t e r i l i s e db y a u t o c l a v i n g .S i n c et h ei n t e r n a lt e m p e r a t u r eo fa v i s c o u ss o l u t i o nr i s e ss l o w l y ,a u t o c l a v i n gs h o u l d l a s t l o n g e rt h a n t h e u s u a l2 0m i n u t e s ,i . e . ,3 0 - 4 0m i n u t e s .
d ) Some s t a i n sw h i c hi n t h ep a s th a v eb e e nu s e da s v i t a ls t a i n sw e r e r e c e n t l ys h o w nt o b e c a r c i n o -g e n i c ,e . g . ,t r y p a n b l u e . 5T h o u g ht h i smay b e o fn e g l i g i b l ei m p o r t a n c ei no u r c o n t e x t ,we n o w r e c o m -mend p a t e n t b l u eV s u l p h a nb l u e ) ,w h i c hi sk n o w nn o t t ob e c a r c i n o g e n i c .
e ) A f r e s h l yp r e p a r e ds o l u t i o no fm e t h y l c e l l u l o s ec o n t a i n sc r y s t a l l i n ec o m p l e x e sw h i c hf o r mc o r p u s c u -l a re l e m e n t s .F i l t r a t i o n ,t h e r e f o r e ,i sa n e s s e n t i a lp a r to f t h ep r e p a r a t i o no f a s o l u t i o nd e s t i n e df o ri n t r a -o c u l a ru s e .
P r e p a r a t i o no f 1 0 0m l o fa 2 s o l u t i o no f m e t h y l -c e l l u l o s ei sa sf o l l o w s :D i s s o l v e2 g i n3 0 m l o f b o i l i n gs o l v e n t( B S S , R i n g e r sl a c t a t es o l u t i o n ,R i n g e r ss o l u t i o n ) .A l l o wt o c o o l .A d d 7 0 m l o f c o l do r i c ys o l v e n t .T h es o l v e n tmay c o n t a i n5 m g o f p a t e n t b l u eV s u l p h a nb l u e ) . 5S t o r e i n a r e f r i g e r a t o ro v e r n i g h ta t - 1 0 t o 0 ° C .
N e x td a y t h es o l u t i o nc a n b e f i l t e r e d .T h ep o r es i z e
s h o u l db e b e t w e e n1 6/ A ma n d 0 5 , u m .On e may u s es u c t i o nb y m e a n so f a w a t e r - s t r e a mp u m p t h r o u g haG 3 - F r i t t e ,J e n a e rG l a s s p o r es i z ea p p r o x i m a t e l y1 6, u m )o r m o r ec o n v e n i e n t l yp r e s s u r e n i t r o g e n ) .T h es o l u t i o ni s f i l t e r e dt h r o u g h a S p a r k l e rS u b m i c r o nF i l t e rT u b e ,c a r t r i d g eC S - 0 - 5w i t h a p o r e s i z eo f 0 - 5um S p a r k l e rI n c . ,C o n r o e ,Te x a s ,U S A ) .
A f t e r t h ef i l t e r e ds o l u t i o nh a s b e e n d i v i d e di n t os m a l lb o t t l e s ,t h e s ea r es t e r i l i s e db y a u t o c l a v i n ga t1 2 0 ° Cf o r3 0 - 4 0m i n u t e s .
OPERATIVE TECHNIQUESA l l4 1 7o p e r a t i o n so n w h i c ht h i sp a p e ri sb a s e dw e r ep e r f o r m e db y t h es e n i o ra u t h o ro r i nh i sp r e s e n c eb y a
j u n i o rc o l l e a g u e .T h e l e n s e su s e d w e r e m o s t l yM e d a l l i o n , b u t B i n k h o r s t - f o u r - l o o p , S h e a r i n g ,S i n s k e y ,o r S i n s k e y - K r a t zl e n s e sw e r ea l s oi m p l a n t e d .S i n c et h et y p e o f l e n sh a s n o b e a r i n go n t h e p o s t -o p e r a t i v ei n t r a o c u l a rp r e s s u r e ,i t w i l ln o t b e c o n -s i d e r e df u r t h e ri nt h i sp a p e r .
T h e t e c h n i q u eo f o p e r a t i o nw a s s t a n d a r d i s e da sf o l l o w s .A l l w o u n d sw e r e c o r n e o s c l e r a lu n d e r al i m b u s - b a s e df l a pr e a c h i n g f r o m 9 . 3 0t o 2 . 3 0 .A l li n t r a c a p s u l a ro p e r a t i o n sw e r e p e r f o r m e dw i t h t h eh e l po f a l p h a - c h y m o t r y p s i n e1 :1 0 0 0 0f o r 2 1 / 2m i n u t e s .
A f t e ri m p l a n t a t i o no f t h el e n st h ew o u n dw a sc l o s e dw i t h a p p r o x i m at e l y1 28 - 0 s i l ki n t e r r u p t e ds u t u r e s .D u r i n gt h eo p e r a t i o nm e t h y l c e l l u l o s ew a sa p p l i e di n2d i f f e r e n tw a y s .From 1 9 7 6t o 1 9 7 9o n e d r o p o f a 1
s o l u t i o nw a s
a p p l i e dt ot h ea r t i f i c i a ll e n si m m e d i a t e l y
p r e v i o u st o i t s i n s e r t i o n .S i n c eJ a n u a r y 1 9 8 0 t h ea n t e r i o rc h a m b e rh a s b e e n f i l l e dw i t h a 2 m e t h y l -c e l l u l o s es o l u t i o np r i o rt o i m p l a n t i n gt h el e n s .A f t e rt h el e n sw a s i n p l a c e ,s u t u r e dt o t h ei r i s ,a n d s o m ec o r n e o s c l e r a ls u t u r e sh a d b e e ni n s e r t e d ,m o s to ft h em e t h y l c e l l u l o s ew a sr e m o v e df r o mt h ee y e b y o n e o ft h e f o l l o w i n gm e t h o d s : a )d i l u t i n gi t a n d r i n s i n go u tw i t ha M c I n t y r e - t y p ec o a x i a li n f u s i o na n d a s p i r a t i o nc a n n u l a ; b ) f o r c i n gi t o u t b y i n f l a t i n gt h ea n t e r i o rc h a m b e rw i t h a i r ; c ) a c o m b i n a t i o no f t h e s e2m e t h o d s ,e i t h e rs i m u l t a n e o u s l yo r c o n s e c u t i v e l y .
F o r t h ep a s tf e wm o n t h sa m e t h y l c e l l u l o s es o l u t i o nh a s b e e n u s e dw h i c hi s s t a i n e ds l i g h t l yb l u e t o h e l po b s e r v ei t sd i s a p p e a r a n c e .No a t t e m p tw a s made t or e m o v ea l lt h em e t h y l c e l l u l o s e ,s i n c et h eb l u es p e c k sw h i c hr e m a i n e da t t h ee n d o f t h ep r o c e d u r eh a dd i s a p p e a r e do n t h ef i r s tp o s t o p e r a t i v ed a y .
POSTOPERATIVE MEASURES
A l lp a t i e n t sr e c e i v e dt o p i c a l a p p l i c a t i o n so f d e x a -m e t h a s o n e0- 1 q . i . d .f r o mt h el a s tp r e o p e r a t i v ed a yf o rs e v e r a lw e e k s .T h i sm i g h th a v ec o n t r i b u t e dt ot h ef ac t t h a tt h e r ew a sa s l i g h tr i s eo f p r e s s u r ed u r i n gt h ee a r l yp o s t o p e r a t i v ep e r i o d .T h e r e f o r ea l l p a t i e n t sr e c e i v e da c e t a z o l a m i d ei n s u s t a i n e dr e l e a s ef o r m( D i a m o xS e q u e l s )5 0 0m g d a i l y ,f r o mt h ed a y o ft h e
o p e r a t i o nt o t h et h i r dp o s t o p e r a t i v e d a y .D i a m o xS e q u e l s w a s g i v e ni r r e s p e c t i v eo f w h e t h e r t h eo p e r a t i o nw a s a n i n t r a c a p s u l a r w i t h a l p h a -c h y m o t r y p s i n )o r e x t r a c a p s u l a r w i t h o u ta l p h a -c h y m o t r y p s i n )p r o c e d u r e .T h e p o s t o p e r a t i v ei n t r a -o c u l a rp r e s s u r e so f d a y s 1 t o 3 w e r e u nd e rt h ei n f l u e n c eo fa c e t a z o l a m i d e ;a t d a y 4 t h e r emay h a v eb e e na r e s i d u a le f f e c t .
A p p l a n a t i o nt o n o m e t r yw a sp e r f o r m e da t t h ef i r s t ,t h i r d ,a n d f i f t hp o s t o p e r a t i v ed a y s .A p r e s s u r e -l o w e r i n gt r e a t m e n tw a s r e i n s t i t u t e di n a b o u t 5 o ft h ec a s e so n t h ef i f t hp o s t o p e r a t i v ed a y .T h i sd i d n o ti n f l u e n c et h er e s u l t sp r e s e nt e d b e l ow .
R e s u l t s
OPERATION
T h e u s e o f m e t h y l c e l l u l o s eg r e a t l yf a c i l i t a t e dt h eo p e r a t i o n .I f d e s p i t eo c u l a r m a s s a g et h ea n t e r i o rc h a m b e rr e m a i n e d s h a l l o w ,t h e m e t h y l c e l l u l o sa l w a y si n c r e a s e dt h ed e p t h o f t h ec h a m b e rt o a l l o wf o ra n e a s y a n d s a f ei m p l a n t a t i o n( e v e n o f 3 - p l a n el e n s e sw i t h t h e o p e n - s k yr o u t e )w i t h o u ta S h e e t sg l i d eo r p o s t e r i o r v i t r e c t o m y .T h ei m p l a n t a t i o nn e v e rh a d t ob e a b a n d o n e d ,i nc o n t r a s tt oi t sa b a n d o n m e n t
2 6 0
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M e t h y l c e l l u l o s ea n d l e n si m p l a n t a t i o n
5 0 *
4 0
3 0mm H g
2 0
1 0
5 0
4 0 *
3 0
m m H g
2 0
1 0
A c e t a z o l a m i d e5 0 0 m gp e r d a y
O p 1 s t 2 n d 3 r d 4 t h
P o s t o pd a y
5 t h
F i g .1 P o s t o p e r a t i v ep r e s s u r e s a f t e r3 2 4p l a n n e di n t r a c a p s u l a ro p e r a t i o n sw i t h1 o r 2 m e t h y l c e l l u l o s ea sa n a d j u n c t .A l p h a - c h y m o t r y p s i n1 / 1 00 0 0w a su s e df o r 2 1 / 2m i n u t e si na l lc a s e s .A c e t a z o l a m i d e( D i a m o x )5 0 0m gp e rd a y w a sg i v e nf r o mt h ed a y o ft h eo p e r a t i o nt ot h et h i r dp o s t o p e r a t i v e d a y .
i n a b o u t 10 o f c a s e s p r i o rt o t h eu s e o f m e t h y l -c e l l u l o s e .
A l lt h et y p e so fi n t r a o c u l a rl e n su s e db y u s c o u l db ei m p l a n t e dw i t h o u tt o u c h i n gt h ec o r n e aa n d c o u l d ,a sw a s g e n e r a l l yd o n e , b e s u t u r e dt o t h ei r i sw i t h o u th a r m i n gt h ee n d o t h e l i u m .M o r e o v e r ,i t w a se a s i e rt oo b s e r v et h et y i n go ft h ei r i ss u t u r e k n o t t h r o u g ht h ec o r n e ai ft h ea n t e r i o rc h a m b e rw a sf i l l e dw i t hm e t h y l -
c e l l u l o s er a t h e rt h an w i tha i r .POSTOPERATIVE INTRAOCULAR PRESSURE
W h e n t h ep r e s s u r e sa f t e ru s e o f 1 a n d o f 2m e t h y l c e l l u l o s ew e r e c o m p a r e di t w a s e v i d e n tt h a tt h e y w e r en o h i g h e ra f t e r2 m e t h y l c e l l u l o s e .( T h ep r e s s u r e sw e r es l i g h t l yl o w e ri nf a c t a f t e rb o t h i n t r a -c a p s u l a ra n de x t r a c a p s u l a rp r o c e d u r e s . ) T h e r e f o r et h eg r o u p so fp a t i e n t sr e c e i v i n g1 a n d 2 m e t h y l c e l l u -l o s ew e r e c o m b i n e di n t h ef i g u r e sp r e s e n t e db e l o w.
F i g .1 s h o w st h ep o s t o p e r a t i v ei n t r a o c u l a r p r e s s u r ea f t e rp l a n n e d i n t r a c a p s u l a ro p e r a t i o n s i . e . ,w i t ha p p l i c a t i o no f a l p h a - c h y m o t r y p s i n1 / 1 0 0 0 0f o r2 1 / 2m i n u t e s ) .I t s h o u l db e r e m e m b e r e dt h a tt h ei n t r a -o c u l a rp r e s s u r e sf r o m d a y 1 t h r o u g h d ay3 w e r ei n f l u e n c e db y t h ea p p l i c a t i o no f a c e t a z o l a m i d e .
F i g .2 s h o w st h ei n t r a o c u l a rp r e s s u r ea f t e rp l a n n e de x t r a c a p s u l a ro p e r a t i o n s a l p h a - c h y m o t r y p s i nw a sn o t u s e d i n t h e s ee y e s ,b u t t h ee y e s d i d r e c e i v ea c e t a z o l a m i d e ) .
F i g .3 s h o w st h ei n t r a o c u l a rp r e s s u r ei n a s m a l lg r o u po f s e c o n d a r yi m p l a n t a t i o n so f m e d a l l i o nl e n s e s .T h e s eo p e r a t i o n sd i f f e rf r o mt h o s es h o w ni n F i g s .1a n d 2 i nt h a tt h e yw e r el e s st r a u m a t i c .A c e t a z o l a m i d ew a sg i v e ni nt h e s ec a s e sa l s o .
n = 8 1
1
A c e t a z o l a m i d e500mg p e r d a y
O p 1 s t 2 n d 3 r d 4 t h 5 t hP o s t o p d a y
F i g .2 P o s t o p e r a t i v ep r e s s u r e s a f t e r8 1 p l a n n e de x t r a c a p s u l a ro p e r a t i o n s .M e t h y l c e l l u l o s e1 a n d2 w a su s e da sa n a d j u n c ti na l lc a s e s .No o p e r a t i o nw a sp e r f o r m e dw i t he n z y m a t i cz o n u l o l y s i s .A c e t a z o l a m i d e( D i a m o x )5 0 0m g p e r d a y w a sg i v e nf r o mt h ed a y o f t h eo p e r a t i o nt ot h et h i r dp o s t o p e r a t i v ed a y .
T h e3 f i g u r e sd e m o n s t r a t ec l e a r l yt h a tt h ei n c r e a s e si ni n t r a o c u l a rp r e s s u r ea f t e ra c a t a r a c to p e r a t i o nw i t hl e n si m p l a n t a t i o n o ra f t e ra s e c o n d a r yl e n si m p l a n t a -t i o n ) ,d u r i n gw h i c hm e t h y l c e l l u l o s eh a s b e e na p p l i e d ,a r e n o t a c o m p l i c a t i o no f c l i n i c a ls i g n i f i c a n c e .
POSTOPERATIVE INFLAMMATION
No p o s t o p e r a t i v ei n f e c t i o n so c c u r r e d . P os s i b l y
b e c a u s e o f s t e r o i dt r e a t m e n t p o s t o p e r a t i v ei n t r a -o c u l a ri n f l am m at i o n w a sm i n i m a l .O n l ys l i g h tf l a r e
5 0
4 0 -
3 0 -mm H g
2 0
1 0
n = 1 2
T T_ _
A c e t a z o l a r r i d e5 0 0 m g p e r d a y
O p 1 S t 2 n d 3 r d 4 t hP o s t o pd ay
5 t h
F i g .3 P o s t o p e r a t i v e p r e s s u r e sa f t e r1 2 s e c o n d a r yl e n si m p l a n t a t i o n so f m e d a l l i o nl e n s e sw i t h1 or2m e t h y l c e l l u l o s eu s e da sa n a d j u n c t .A c e t a z o l a m i d e( D i a m o x )5 0 0m gp e r d a y w a sg i v e nf r o mt h ed ay o ft h eo p e r a t i o nt ot h et h i r dp o s t o p e r a t i v ed a y .
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P a u l U .F e c h n e ra n d M a r t i nU . F e c h n e r
a n d a f e w c e l l sw e r e o b s e r v e df o r a f e w d a y s .Noh y p o p y o no c c u r r e d . A l l l e n s e sh a d b e e n w e t -s t e r i l i s e db y M e d i c a lW o r k s h o p . )O n l y a f e w eyes
w i t h a more p r o n o u n c e de x u d a t i o nw e r e o b s e r v e d .
T h i s c o u l d n o t h a v e b e e n t h er e s u l to f
t h em e t h y l -
c e l l u l o s e ,b e c a u s e t h e m e t h y l c e l l u l o s ewas a l w a y sw i t h d r a w nf r o mo n e b o t t l ef o r s e v e r a li m p l a n t a t i o n s ,w h i l et h e p o s t o p e r a t i v eca se s o f i r i t i so c c u r r e do n l ys p o r a d i c a l l y ,n e v e r e p i d e m i c a l l y .
POSTOPERATIVE S T AT E OF THE CORNEA
E a c ho p e r a t i o nw a s g r a d e da c c o r d i n gt o a s u b j e c t i v ei m p re s s i o n o fq u a l i t y ,a n d l a t e rc o m p a r e dw i t h t h ep o s t o p e r a t i v ea p p e a r a n c e o f t h ec o r n e a . I nt h eca se s
w i t h t h e h i g h e s tg r a d e ( m o s te y e s ) ,t h ec o r n e a e were
n e a r l y c l e a ra t t h e f i r s t p o s t o p e r a t i v ed a y , a n dc o m p l e t e l yc l e a rb y t h e t h i r dd a y .
Th e e n d o t h e l i u mwas o b s e r v e dp o s t o p e r a t i v e l yi na b o u t 1 0 0 cases b y n o n c o n t a c ts p e c u l a rm i c r o s c o p ya n d w i t h t h e h e l p o f a M c I n t y r eg r i da n d c o m p a r e dw i t h t h e n o n o p e r a t e de y e . I n mos t o f t h e o p e r a t e de y e s t h e r e w e r e a b o u t 2 0 0 0 e n d o t h e l i a lc e l l sp e r
s q u a r e i nb o t h e y e s . T o u s t h i si n d i c a t e da l a c ko fa n y t o x i ce f f e c to f m e t h y l c e l l u l o s eon t h e e n d o -t h e l i u m .
T h e r e f o r ea s a c l i n i c a li m p r e s s i o non t h eb a s i so fa p p r o x i m a t e l y 2 , 0 0 0 p o s t o p e r a t i v es l i t - l a m pe x a m i n a t i o n so n 4 1 7 e y e s i t c a n b e s t a t e d t h a tm e t h y l c e l l u l o s ed i d n o t h a r mt h ee n d o t h e l i u m .S i n c et h e m e c h a n i c a la d v a n t a g eo f t h i sa d j u n c t t o t h eo p e r a t i o n i s so e v i d e n t ,t h eo v e r a l le f f e c ton t h e
c o r n e a mus t o b v i o u s l yb e b e n e f i c i a l .D i s c u s s i o n
H e a l o nwas r e c e n t l yc o n s i d e r e d t h em o s t i m p o r t a n ts u b s t a n c e t o come a l o n g i n c a t a r a c t s u r g e r y s i n c ea l p h a - c h y m o t r y p s i n ' .6 T h i s s t a t e m e n t , h o w e v e r ,must b e q u a l i f i e d .W h a t m a t t e r s i s n o t H e a l o nb u ta p p r o p r i a t e v i s c o u sm a t e r i a li n t h e e y e . H e a l o n ,d e s p i t ei t s v a l u e ,h a s i t s d i s a d v a n t a g e s :i t i s v e r y
e x p e n s i v e ,n o t u n i v e r s a l l ya v a i l a b l e ,a n d i t i sd i f f i c u l tt o d i l u t e .F o r t h e l a s tr e a s o n a r e l a t i v e l y l a r g ea m o u n to f t h e m a t e r i a lmay r e m a i ni n t h ee y e a n d c a u s e a
d a n g e r o u s r i s e o f pres su re p o s t o p e r a t i v e l y .1 7
We p r e f e rm e t h y l c e l l u l o s e2 d i s s o l v e di n B S S .F l e m i n ge t a l . 8 h a v e s h o w nt h a tm e t h y l c e l l u l o s ei n s i d et h e e y e i s h a r m l e s s .M e t h y l c e l l u l o s eh a s many
a d v a n t a g e s .As a n a d j u n c t t o l e n si m p l a n t a t i o ni t i sp e r f e c t .I t c o a t s t h e l e n sa n d d e e p e n sa s h a l l o wa n t e r i o r c h a m b e r . I t i s u n i v e r s a l l ya v a i l a b l ea n di n e x p e n s i v e .T h e s o l u t i o ni s c o m p a r a t i v e l ye a s y t o
p r e p a r e - a t l e a s t f o r a m o d e r a t e l y e q u i p p e dp h a r m a c y .T h i s i s a d v a n t a g e o u si n u n d e r d e v e l o p e da n d d e v e l o p i n gc o u n t r i e s .T h e s o l u t i o ncan b er e s t e r i l i s e d ,t h e r e b y f u r t h e rd e c r e a s i n g t h e c o s t
f a c t o r .I t c a n b e s t a i n e db l u ef o re a s y r e c o g n i t i o ni n s i d et h ea n t e r i o rc h a m b e r .I t i s - a n d t h i si s a v e r yi m p o r t a n t p o i n t - e a s i l yd i l u t e da n d c a n b e l a r g e l yr e m o v e df r o m t h ea n t e r i o rc h a m b e rw i t h o u td i f f i -c u l t y .I f p o s t o p e r a t i v er i s e so f i n t r a o c u l a rp r e s s u r eo c c u ro w i n gt oi t su s e ,t h e ya r e e a s i l ym a n a g e a b l ea n dn o t c l i n i c a l l ys i g n i f i c a n t .
B e c a u s em e t h y l c e l l u l o s ei s a n o n p h y s i o l o g i c a la n dp o s s i b l yn o n m e t a b o l i cs u b s t a n c ec o n s i s t i n go f l a r g ep o l y m e r s ,i t c o u l db e a r g u e dt h a tt h e r e s i d u ew h i c hr e m a i n si n t h ee y e a t t h ee n d o f t h eo p e r a t i o nm i g h tc l o gt h et r a b e c u l a rm e s h w o r ka n d c a u s e d a n g e r o u sb o u t so fg l a u c o m a ,a sh a s b e e nr e p o r t e da f t e rt h eu s eo f H e a l o n ' O u r r e s u l t ss h o wt h a tt h i si s d e f i n i t e l yn o t s o .As c a n b e s e e n f r o mF i g s .1 a n d 2 , t h ei n t r a -o c u l a rp r e s s u r ea t t h ef i r s tp o s t o p e r a t i v ed a yw a s3 3 - 1mmHg a f t e ri n t r a c a p s u l a ro p e r a t i o n ,a n d3 0 - 2m m H ga f t e re x t r a c a p s u l a ro p e r a t i o n w i t ha c e t a z o l a m i d e ) .O b v i o u s l yt h ed i f f e r e n c eb e t w e e nt h ep r e s s u r e sm u s tb e d u e t o t h e i n c r e a s e dt e n s i o nf o l l o w i n gt h ee n z y m a t i cz o n u l o l y s i s .B u t e v e n a f t e re x t r a c a p s u l a ro p e r a t i o np r e s s u r er i s e so c c u r w h i c hs e e m i n t h ef i r s tp l a c et o b e d u e t o t h et r a u m ao f t h eo p e r a t i o na n d l e n sm a t e r i a lr e m a i n i n gi n t h ea n t e r i o rc h a m b e r .I t i s u n c l e a rw h e t h e rr e m n a n t so f m e t h y l c e l l u l o s ei nt h ea n t e r i o rc h a m b e ri n a d d i t i o ni n c r e a s et h ep o s t -o p e r a t i v ei n t r a o c u l a rp r e s s u r e .W h e t h e rt h i si s so -a n d i f s o , t o w h a t e x t e n t - c o u l dn o t b e c l a r i f i e d .W h a tw a s s h o w n ,h o w e v e r ,w a s t h eu n e q u i v o c a l l yb e n i g nb e h a v i o u ro f t h em e t h y l c e l l u l o s ei n s i d et h ee y e w i t hr e s p e c tt o t h ep o s t o p e r a t i v ep r e s s u r e .
As r e g a r d st h e a r g u m e n tt h a t m e t h y l c e l l u l o s ec a n n o t b e m e t a b o l i s e d ,o n e m u s t c o n s i d e rt h eq u a n t i t yu n d e r d i s c u s s i o n .I f 20 o f w h a t w a si n j e c t e di n t ot h e e y e - s a y 0 - 5m l - s t a y s i n t h ea n t e r i o rc h a m b e r ,t h i sa m o u n t st o o n l y2 m g o f t h ed r y s u b s t a n c e o f m e t h y l c e l l u l o s e ,a s u b s t a n c ec o n s i d e r e d t o b e i n e r t a n d c o n f i r m e db y o u re x p e r i e n c et o b e s o .None o ft h ep a t i e n t ss h o w e da n yi l le f f e c te i t h e rs y s t e m i c a l l yo r l o c a l l yw h i c hc o u l db er e l a t e dt om e t h y l c e l l u l o s e .
W i t hr e s p e c tt o t h ec o r n e awe d i dn o t p r o v et h a tm e t h y l c e l l u l o s ew a s m o r eb e n e f i c i a lt h a n H e a l o no ra i ro r n o c u s h i o n i n gs u b s t a n c ea t a l l .B u t s i n c em o s te y e s w h i c hw h e r ee x a m i n e db y n o n c o n t a c ts p e c u l a rm i c r o s c o p yd i ds h o w a v e r y h i g he n d o t h e l i a lc e l lc o u n t p r a c t i c a l l ye q u a l t o t h a to f t h e n o n o p e r a t e de y e s )we f e e lj u s t i f i e di n t h e a s s u m p t i o nt h a tm e t h y l -c e l l u l o s ei sa t l e a s tn o t t o x i ct ot h ee n d o t h e l i u m .T h a ti t i so f b e n e f i ti s a b e l i e fb a s e do n o u re x p e r i e n c et h a ti m p l a n t a t i o ni n s o many c a s e si s m u c h f a c i l i t a t e db yi t su s e .
I n s u m m a r y ,o u r e x p e r i e n c eo f o v e r 6y e a r sw i t hm e t h y l c e l l u l o s el e a d su s t ob e l i e v et h a tt h i ss u b s t a n c ei s m o s tv a l u a b l e i n i n t r a o c u l a rs u r g e r yw h e n e v e rac u s h i o n i n gs u bs t an c e o t h e r t h ana i ri s n e e d e di n t h e
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M e t h y l c e l l u l o s ea n d l e n si m p l a n t a t i o n
a n t e r i o rc h a m b e r .A d m i t t e d l yt h i ss t a t e m e n ti sb a s e do n c l i n i c a le x p e r i e n c e .We h o p et h a tt h i sp a p e r may
s t i m u l a t ef u r t h e ri n v e s t i g a t i o n st o o b t a i n c o n -
f i r m a t i o n .
We o b t a i n e dt h es o l u t i o no f m e t h y l c e l l u l o s ef r o m R at h s - Ap o t h e ke ,O s t e r - S t5 1 ,3 2 5 0H a m e l n , W e s tG e r m a n y .
R e f e r e n c e s
I L a i n g R A , S a n d s t r o mM M L e i b o w i t zH M . I n v i v op h o t o -m i c r o g r a p h yo f t h ec o r n e a le n d o t h e l i u m .A r c hO p h t h a l m o l1 9 7 5 ;9 3 : 1 4 3 - 5 .
2 B o u r n e M K a u f m a nH E. S p e c u l a rm i c r o s c o p yo f humanc o r n e a le n d o t h e l i u mi nv i v o .Am J O p h t h a l m o l1 9 7 6 ;8 1 :3 1 9 - 2 3 .
3 H o f f e r J , P h i l i p p iG . A c e l lm e m b r a n et h e o r yo f e n d o t h e l i a lr e p a i ra n d v e r t i c a lc e l ll o s sa f t e rc a t a r a c t s u r g e r y . Am I n t r a - o c u l a rI m p l a n tS o cJ 1 9 7 8 ;4 : 1 8 - 2 5 .
4 F e c h n e rP U . I n t r a o c u l a rl e n s e s .S t u t t g a r t :E n k e ,1 9 8 0 :6 6 .5 N o r n M S . V i t a ls t a i n i n go f c o r n e a le n d o t h e l i u mi n c a t a r a c t
e x t r a c t i o n .A c t aO p h t h a l m o l( K b h )1 9 7 1 ;4 9 :7 2 5 - 3 3 .6 E d e l h a u s e r F , va n H o r nD L , S c h u l t zR H y n d i u kR A .
C o m p a r a t i v et o x i c i t yo f i n t r a o c u l a ri r r i g a t i n gs o l u t i o n son t h ec o r n e a le n d o t h e l i u m .Am J O p h t h a l m o l1 9 7 6 ;8 1 :4 7 3 - 8 1 .
7 E d e l h a u s e rH F , C o nn e r i n g R ,va n H o r n D L . I n t r a o c u l a ri r r i g a t i n gs o l u t i o n s .A r c hO p h t h a l m o l1 9 7 8 ;9 6 : 5 1 6 - 2 0 .
K a u f m a nH E , K a t zJ . E n d o t h e l i a ld a m a g ef r o mi n t r a o c u l a rl e n si n s e r t i o n. I n v es tO p h t h a l m o lV i s u a lS c i 1 9 7 6 ;1 5 :9 9 6 - 1 0 0 0 .
9 K a u f m a nH E , K a t zJ . E n d o t h e l i a ld a m a g ef r o mi n t r a o c u l a rl e n si n s e r t i o n .I n v e s tO p h t h a l m o lV i s u a lS c i 1 9 7 7 ;1 6 :2 6 5 .
1 0 B i n k h o r s tC D , L o o n e s ,L H , N y g a a r dP . D i e B e d e u t u n gd e rS p i e g e l m i k r o s k o p i eu n d- g r a p h i ed e s H o r n h a u t e n d o t h e l sf u rd i eE i n p f l a n z u n gk u n s t l i c h e rA u g e n l i n s e n . B e s c h r e i b u n ge i n e rT i e f k a m m e r t e c h n i kf u r E i n p f l a n z u n g .B e rD t s c hO p h t h a l m o lG e s1 9 7 8 ;7 5 : 9 3 - 1 0 3 .
1 1 F e c h n e rP U . M e t h y l c e l l u l o s ei n l e n si m p l a n t a t i o n .Am I n t r a -O c u l a rI m p l a n tS o cJ 1 9 7 7 ;3 : 1 8 0 - 1 .
1 2 F e c h n e rP U . E rf a h ru n g e nm i td e r I m p l a n t a t i o ne i n e rk u n s t l i c h e nA u g e n l i n s e .K l i nM o n a t s b l A u g e nh e i l k d1 9 7 9 ;1 7 2 :8 5 2 - 6 2 .
1 3 F e c h n e rP U . M e t h y l c e l l u l o s ea l sG l e i t s u b s t a n zf u rd i eI m p l a n t a -t i o nk u n s t l i c h e rA u g e n l i n s e n .K l i nM o n a t s b lA u g e n h e i l k d1 9 7 9 ;1 7 4 : 1 3 6 - 1 8 .
1 4F e c h n e rP U . U s e o fm e t h y l c e l l u l o s ed u r i n gl e n si m p l a n t a t i o n .Am I n t r a - O c u l a rI m p l a n tS o c J1 9 8 0 ;6 :3 6 8 - 9 .
1 5 M a r t i n d a l e :t h ee x t r ap h a r m a c o p o e i a .2 7 t he d .L o n d o n :P h a r m a -c e u t i c a lP r e s s , 1 9 7 7 : 4 7 5 ,6 1 5 .
1 6D r e w sR C .T h eh i g h l i g h t so n i n t r a o c u l a rl e n s e s ,m e r i t so fe x t r a -c a p s u l a r sv e r s u si n t r a c a p s u l a r s .I n : B o y dB , e d . H i g h l i g h t so fo p h t h a l m o l o g y .2 5 t he d .P a n a m a ,H i g h l i g h t so f O p h t h a l m o l o g y :1 9 8 1 ;2 :9 0 4 .
1 7 B i n k h o r s tC D . I n f l am m a t i o n a n di n t r a o c u l a rp r e s s u r ea f t e rt h eu s e o f H e a l o n i n i n t r a o c u l a rl en s s u r g e r y .Am I n t r a - O c u l a rI m p l a n tS o cJ 1 9 8 0 ;6 :3 4 0 - 1 .
1 8F l e m i n gM A , M e r r i l lD L , G i r a r d L J . S t u d i e so ft h ei r r i t a t i n ga c t i o no fm e t h y l c e l l u l o s e .A r c hO p h t h a l m o l1 9 5 9 ;6 1 :5 6 5 - 7 .
2 6 3
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8/19/2019 Methylcellulose and Lens Implantation.br J Ophthalmol-1983-Fechner-259-63
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Methylcellulose and lens implantation.
P. U. Fechner and M. U. Fechner
doi: 10.1136/bjo.67.4.2591983 67: 259-263Br J Ophthalmol
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