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Optimal Method for Mydriasis in Cataract Surgery

Primary Purpose

Cataract

Status
Terminated
Phase
Not Applicable
Locations
United States
Study Type
Interventional
Intervention
Topical phenylephrine 2.5%
Topical cyclopentolate 1%
Intracameral Lidocaine 1%
Intracameral 0.2- 0.3ml of epinephrine 1:10,000
Sponsored by
Johns Hopkins University
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional other trial for Cataract

Eligibility Criteria

40 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

Patients aged 40 or older who are undergoing routine cataract surgery under topical anesthesia with monitored anesthesia care at the Wilmer Eye Institute with Dr. Fasika Woreta and her senior resident proficient at cataract surgery.

Exclusion Criteria:

  • Need for general anesthesia
  • Maximum pupillary dilation <6.0mm at the pre-op clinic visit.
  • Prior intra-ocular surgery
  • Prior trauma
  • Any pre-existing iris abnormalities including pupillary deformity, posterior synechiae, peripheral anterior synechiae, zonular dehiscence
  • Pseudoexfoliation
  • Allergy to any of the mydriasis agents
  • Pregnancy or breastfeeding

Sites / Locations

  • Wilmer Eye Institute, Johns Hopkins

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm Type

Experimental

Experimental

Experimental

Arm Label

Topical Mydriasis

Intracameral Mydriasis

Topical + Intracameral mydriasis

Arm Description

Topical mydriasis will be with 1 drop of phenylephrine 2.5% and 1 drop of cyclopentolate 1% x 4 doses each, with each drop spaced 5 minutes apart given in the pre-op area. These are the standard dilating drops used for cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia.

Intracameral mydriasis will be with 0.2ml to 0.3ml of epinephrine 1:10,000 injected into the anterior chamber at the beginning of the cataract surgery procedure. This is the standard concentration use for intracameral mydriasis in cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia.

Topical mydriasis will be with 1 drop of phenylephrine 2.5% and 1 drop of cyclopentolate 1% x 4 doses each, with each drop spaced 5 minutes apart given in the pre-op area. These are the standard dilating drops used for cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia. Intracameral mydriasis will be with 0.2ml to 0.3ml of epinephrine 1:10,000 injected into the anterior chamber at the beginning of the cataract surgery procedure. This is the standard concentration use for intracameral mydriasis in cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia.

Outcomes

Primary Outcome Measures

Pupil Size Immediately Prior to Capsulorrhexis
Pupil size immediately prior to the capsulorrhexis step of cataract surgery. This will be recorded by digital photography and measured by a researcher who is masked to the intervention.

Secondary Outcome Measures

Pupil Size (mm) Immediately After Nuclear Disassembly
Pupil size immediately after breaking up of cataractous lens
Pupil Size Immediately Prior to Intraocular Lens (IOL) Insertion
Pupil size after insertion of IOL lens
Pupil Size Upon Completion of Surgery
Pupil Size on Post-operative Day 1
Percentage of Patients in Each Arm That Required Another Mydriatic Agent
Cumulative Energy Dispersed for Each Arm
The amount of energy needed to break up the cataractous lens
Mean Time Taken to Perform Phacoemulsification in Each Arm
Percentage of Patients With an Increase in the Blood Pressure or Heart Rate
Percentage of Patients With an Increase in the Blood Pressure or Heart Rate
Mean Time Taken to Perform Phacoemulsification
Percentage of Patients in Each Arm That Required Use of an Iris Expansion Device During the Procedure

Full Information

First Posted
September 19, 2016
Last Updated
August 22, 2019
Sponsor
Johns Hopkins University
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1. Study Identification

Unique Protocol Identification Number
NCT02909140
Brief Title
Optimal Method for Mydriasis in Cataract Surgery
Official Title
Optimal Method for Mydriasis in Cataract Surgery
Study Type
Interventional

2. Study Status

Record Verification Date
August 2019
Overall Recruitment Status
Terminated
Why Stopped
insufficient patient recruitment
Study Start Date
September 2016 (Actual)
Primary Completion Date
August 15, 2018 (Actual)
Study Completion Date
August 15, 2018 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Johns Hopkins University

4. Oversight

Data Monitoring Committee
No

5. Study Description

Brief Summary
Obtaining appropriate mydriasis prior to cataract surgery is an important variable in successful surgery. The current practice includes using topical anticholinergic and sympathomimetic agents in the preoperative area prior to cataract surgery, but the pupils are sometimes insufficiently dilated and can often need additional mydriasis with intracameral agents during cataract surgery. Pre-operative topical mydriatic drops take time to take effect, are mildly uncomfortable for the patient, and have a cost to the healthcare system. If intracameral mydriasis alone can achieve adequate pupil dilation, perhaps topical mydriatics would not be needed. The purpose of this study is to evaluate whether topical versus intracameral versus topical + intracameral mydriasis is the optimal way to dilate pupils during routine cataract surgery. The results of this study have implications for improving the efficiency and reducing time prior to cataract surgery. In addition, it has significant potential to reduce the cost associated with cataract surgery if preoperative drops can be eliminated.
Detailed Description
Recent research has compared the use of intracameral and topical agents with the preoperative pupil size and cataract surgery success. Studies have compared topical mydriatics with intracameral lidocaine and found no significant difference in dilation. , Other studies have compared topical mydriatics with intracameral dilation that includes solutions with and without epinephrine in the irrigating solution and concluded that irrigating solutions without epinephrine can safely be used with intracameral mydriatics but epinephrine is useful when using topical mydriatics. There have also been studies comparing the success of longer acting drug inserts of mydriatic agents with the use of intracameral agents. In addition to these standard agents, different surgeons have used various formulations of topical and intracameral agents to perform mydriasis. As of yet, there is no formal, standardized method for mydriasis and no large prospective study comparing the outcomes of the various methods. Considerations such as cost and time spent on preoperative mydriatic agents in light of the amount of success seen with these agents calls into question the need for such agents. The investigators would like to study the amount of pupillary dilation seen with topical preoperative mydriatic agents compared to intracameral agents compared to the use of them both together. This will be a prospective randomized controlled trial. Patients will be consented and enrolled at their pre-op visit. They will be randomized to topical drops alone, intracameral injection alone, or topical plus intracameral mydriasis. All patients will receive intracameral lidocaine, as this is used for its anesthetic effect but also has some mydriatic effect. The intervention will take place on the day of the operation. Patients will be followed until post-operative month #1. Data will be gathered on 4 visits: pre-op clinic visit, day of operation, and post-operative day #1 and post-operative month #1. These are all standard visits for routine cataract surgery, and this study will not require the patient to make any extra visits. Enrollment will continue until the sample size is met. Patients cannot be blinded to whether or not they receive topical mydriasis eyedrops, and no placebo drops are necessary because patients cannot voluntarily control their pupillary constriction, so no placebo effect would be expected. The surgeon cannot be blinded to whether or not the patient has received topical mydriasis eyedrops in the pre-op area because it will be evident based upon whether or not the patient's eye is dilated. Another researcher who was not present in the operating room will grade the photographs and measure the pupil size, and this researcher will be blinded to which intervention the patient received. Currently, some surgeons use topical plus intracameral mydriasis for mydriasis during cataract surgery. It is hypothesized that intracameral mydriasis alone may be sufficient to adequately dilate the pupil for cataract surgery. Patients who are not adequately dilated at the time of pupil size measurement immediately before the capsulorrhexis step will subsequently receive additional pharmacologic mydriasis, visco-dilation, or iris expansion devices to dilate their pupil to a size that is adequate for their surgery. Therefore, no matter which group the patient is in, their pupil will be eventually dilated to a size that is adequate to proceed with surgery. There is no placebo or non-treatment group, since all patients must be somehow dilated in order to undergo cataract surgery. The purpose of this study is to compare 3 methods of dilation. The pupil size will be measured after the viscoelastic is injected and before the capsulorrhexis is performed. Treatment failure is defined as a pupil size that is clinically deemed too small to safely proceed with surgery (approximately less than 5 mm). At this point, a rescue intervention will be implemented with additional pharmacologic mydriasis, visco-dilation, or iris expansion devices, until the pupil is adequately dilated to proceed with surgery. These patients will still be included in the study, and their pupil size prior to the rescue intervention is still the primary outcome. Participants can choose to stop participating in the study prior to receiving any of the mydriasis agents. Should they choose to withdraw from the study, they would end up receiving routine mydriasis with topical plus intracameral agents. The study ends on post-op month #1 for all individual patients. The study enrollment period will end when the sample size is met.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Cataract

7. Study Design

Primary Purpose
Other
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
3 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Topical Mydriasis
Arm Type
Experimental
Arm Description
Topical mydriasis will be with 1 drop of phenylephrine 2.5% and 1 drop of cyclopentolate 1% x 4 doses each, with each drop spaced 5 minutes apart given in the pre-op area. These are the standard dilating drops used for cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia.
Arm Title
Intracameral Mydriasis
Arm Type
Experimental
Arm Description
Intracameral mydriasis will be with 0.2ml to 0.3ml of epinephrine 1:10,000 injected into the anterior chamber at the beginning of the cataract surgery procedure. This is the standard concentration use for intracameral mydriasis in cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia.
Arm Title
Topical + Intracameral mydriasis
Arm Type
Experimental
Arm Description
Topical mydriasis will be with 1 drop of phenylephrine 2.5% and 1 drop of cyclopentolate 1% x 4 doses each, with each drop spaced 5 minutes apart given in the pre-op area. These are the standard dilating drops used for cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia. Intracameral mydriasis will be with 0.2ml to 0.3ml of epinephrine 1:10,000 injected into the anterior chamber at the beginning of the cataract surgery procedure. This is the standard concentration use for intracameral mydriasis in cataract surgery. These patients will also receive intracameral lidocaine 1% for anesthesia.
Intervention Type
Drug
Intervention Name(s)
Topical phenylephrine 2.5%
Intervention Type
Drug
Intervention Name(s)
Topical cyclopentolate 1%
Intervention Type
Drug
Intervention Name(s)
Intracameral Lidocaine 1%
Intervention Type
Drug
Intervention Name(s)
Intracameral 0.2- 0.3ml of epinephrine 1:10,000
Primary Outcome Measure Information:
Title
Pupil Size Immediately Prior to Capsulorrhexis
Description
Pupil size immediately prior to the capsulorrhexis step of cataract surgery. This will be recorded by digital photography and measured by a researcher who is masked to the intervention.
Time Frame
Immediately prior to the capsulorrhexis step of cataract surgery
Secondary Outcome Measure Information:
Title
Pupil Size (mm) Immediately After Nuclear Disassembly
Description
Pupil size immediately after breaking up of cataractous lens
Time Frame
Immediately after nuclear disassembly step of cataract surgery
Title
Pupil Size Immediately Prior to Intraocular Lens (IOL) Insertion
Description
Pupil size after insertion of IOL lens
Time Frame
Immediately prior to IOL insertion step of cataract surgery
Title
Pupil Size Upon Completion of Surgery
Time Frame
intraoperative
Title
Pupil Size on Post-operative Day 1
Time Frame
Post-operative Day 1
Title
Percentage of Patients in Each Arm That Required Another Mydriatic Agent
Time Frame
intraoperative
Title
Cumulative Energy Dispersed for Each Arm
Description
The amount of energy needed to break up the cataractous lens
Time Frame
During cataract surgery
Title
Mean Time Taken to Perform Phacoemulsification in Each Arm
Time Frame
intraoperative
Title
Percentage of Patients With an Increase in the Blood Pressure or Heart Rate
Time Frame
Baseline
Title
Percentage of Patients With an Increase in the Blood Pressure or Heart Rate
Time Frame
intraoperative
Title
Mean Time Taken to Perform Phacoemulsification
Time Frame
During cataract surgery
Title
Percentage of Patients in Each Arm That Required Use of an Iris Expansion Device During the Procedure
Time Frame
intraoperative

10. Eligibility

Sex
All
Minimum Age & Unit of Time
40 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients aged 40 or older who are undergoing routine cataract surgery under topical anesthesia with monitored anesthesia care at the Wilmer Eye Institute with Dr. Fasika Woreta and her senior resident proficient at cataract surgery. Exclusion Criteria: Need for general anesthesia Maximum pupillary dilation <6.0mm at the pre-op clinic visit. Prior intra-ocular surgery Prior trauma Any pre-existing iris abnormalities including pupillary deformity, posterior synechiae, peripheral anterior synechiae, zonular dehiscence Pseudoexfoliation Allergy to any of the mydriasis agents Pregnancy or breastfeeding
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Fasika Woreta, M.D., M.P.H
Organizational Affiliation
Johns Hopkins University
Official's Role
Principal Investigator
Facility Information:
Facility Name
Wilmer Eye Institute, Johns Hopkins
City
Baltimore
State/Province
Maryland
ZIP/Postal Code
21287
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
No

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Optimal Method for Mydriasis in Cataract Surgery

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