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Purpose: To compare pupil dynamics after using premixed intracameral anesthetic mydriatic combination (ICAM) of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) versus topical mydriatic (TM) drops consisting of tropicamide 0.8%, phenylephrine 5%, and cyclopentolate 0.5% in pediatric cataract surgery., Design: Randomized, masked, fellow eye-controlled trial., Setting: Tertiary eye care facility., Study Population: Children ≤12 years of age with bilateral cataracts planned for surgery. One eye was randomized to receive ICAM and the other eye (control) TM drops., Intervention: Commercially available ICAM that was injected at the beginning of surgery or TM 3 times at an interval of 30 minutes, 1 hour before the scheduled time of surgery. The other treatment was administered for the second eye cataract surgery., Main Outcome Measure: Pupil dynamics at various points of surgery were studied by a masked observer., Results: Sixty-three patients (126 eyes) were randomized to receive ICAM in 1 eye (group 1) or TM drops (group 2). The mean age of the children in the study was 15.7 ± 24.3 months (range 3 months to 5 years). Adequate mydriasis with a single injection was achieved in 93.5% of patients in group 1 and 88.8% of patients in group 2 without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.78 mm to 5.1 mm after injection of 1 unit of ICAM and from 1.75 mm to 6.06 mm with TM drops (P < .0001). The maximum pupillary dilation achieved was 6.06 ± 1.17 mm in group 1 and 6.75 ± 1.07 mm in group 2 (P = .004). The average change in pupillary size from injection of drug until the end of surgery was positive in group 1 (0.75 ± 0.98 mm) and negative in group 2 (-0.3348 ± 2.57 mm), ie, there was a relative miosis in group 2 toward the end of surgery (P = .001)., Conclusions: Topical drugs achieved a larger maximum pupil size compared with ICAM. However, ICAM provided adequate and stable mydriasis without the need for augmentation compared with topical drops in children undergoing cataract surgery., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To investigate the effects of topically applied 1% tropicamide, 2.5% phenylephrine and 1% cyclopentolate on retinal vessel calliper (VC) using optical coherence tomography (OCT)., Methods: Patients who came to the ophthalmology clinic for routine examination and whose OCT films were taken before dilatation and after 30 min of last dilatation drop were included in the study. 90 ophthalmologically healthy subjects were divided into 3 groups of 30 subject each according to the application of the drops as follows: Tropicamide group (Group 1), Phenylephrine group (Group 2), Cyclopentolate group (Group 3). The right eyes of the subjects were dilated with drops and the left eyes were taken as the control group. VC of retinal artery and vein passing through an area one-half to one-disc diameter from the optic disc margin were measured from OCT films. The mean of the sum of superior retinal artery (SRA) and inferior retinal artery (IRA) VC and the mean of the sum of superior retinal vein (SRV) and inferior retinal vein (IRV) VC before and after the drop were compared., Results: There was no statistically significant change in the mean sum of SRA and IRA VC and the mean sum of SRV and IRV VC before and after dilatation drops in all three groups., Conclusion: Dilatation drops have no statistically significant effect on retinal artery and vein VC.

Significance: This study explores the difference between cycloplegic and noncycloplegic refraction in young adult myopes., Purpose: From the available literature, it is unclear whether cycloplegia is necessary when refracting young adults. This study investigates the agreement between noncycloplegic autorefraction and cycloplegic autorefraction and investigates factors affecting the agreement between the two methods., Methods: In total, 125 myopes with ages ranging between 18 and 26 years were included from Australia and Vietnam. Each participant underwent noncycloplegic autorefraction and cycloplegic autorefraction. Cycloplegia was induced with 1% ophthalmic tropicamide., Results: The mean spherical equivalent difference (95% confidence interval) between noncycloplegic autorefraction and cycloplegic autorefraction was -0.20 D (-0.25 to -0.14 D; t124 = -7.18, p<0.0001 ) . A mean difference of >0.25 D was seen in 46.8% of eyes. The lower and upper limits of agreement were -0.80 and 0.41 D, respectively. With univariate analysis, factors including age, degree of refractive error, accommodation amplitude, and distance phorias showed no impact on the average difference between cycloplegic autorefraction and noncycloplegic autorefraction. Yet, eyes with near exophoria ( F2,120 = 6.63, p=0.0019) and Caucasian eyes ( F3,121 = 2.85, p=0.040) exhibited the smallest paired differences. However, in the multivariate analysis, only near exophoria was associated with a lower mean difference. A significantly smaller proportion (34.9%) of eyes with near exophoria had a paired difference of -0.25 D or more compared with esophoria (50%) and orthophoria (65%; χ2 = 6.6, p=0.038)., Conclusions: Noncycloplegic autorefraction results in more myopic refractive error than cycloplegic autorefraction in young adults., Competing Interests: Conflict of Interest Disclosure: None of the authors have reported a financial conflict of interest., (Copyright © 2024 The Author(s).)

Purpose: To study the pupil dynamics with premixed intracameral anesthetic mydriatic combination of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) in pediatric cataract surgery., Methods: Consecutive children aged ≤12 years planned for cataract surgery were recruited. A commercially available premixed combination of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) was injected at the beginning of surgery without any topical/infusion drugs for mydriasis. Pupil sizes at various points of surgery were studied., Results: We recruited 75 patients with a mean age of 24.3 ± 33.4 months (range: 1 month-11 years). Adequate mydriasis with a single injection was achieved in 93.5% (n = 73 eyes of 70 patients) without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.8 ± 0.79 to 6.1 ± 1.4 mm after injection (mean change of 4.2 ± 1.25 mm from baseline). The mean variability in pupillary diameter was 0.73 ± 1.3 mm. In five eyes, good dilatation was not possible even after repeat injection., Conclusion: Fixed-dose premixed intracameral injection is effective in pupil dilatation. It alleviates the need for any topical dilators or additional intraoperative supplementation for pediatric cataract surgery., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Objective: Mydriatic eye drops used for retinopathy of prematurity (ROP) examination can cause systemic effects, and there are case reports of serious adverse effects in the literature. In this prospective study, we aimed to evaluate the early hemodynamic effects of mydriatic eye drops to understand the possible mechanisms of adverse effects., Study Design: Between December 2018 and March 2019, preterm babies less than 32 gestational weeks and who underwent ophthalmologic examination in our unit were included. The vital signs (heart rate, respiratory rate, oxygen saturation [SpO 2 ], and blood pressure values), cerebral and mesenteric tissue saturation by near-infrared spectroscopy (NIRS), and left ventricular functions of infants were recorded before and after applying mydriatic eye drops (2.5% phenylephrine and 0.5% tropicamide). The data were compared statistically. Strict adherence to prevent systemic absorption of the eye drops was applied., Results: Thirty-two mydriasis procedures were evaluated in 26 patients. The mean gestational age was 28.5 ± 1.7 weeks, and the mean birth weight was 943 ± 233 g. There were no significant differences in terms of vital signs of infants including heart rate, blood pressure, and oxygen saturation [SpO 2 ] levels before and after eye-drop application. In addition, NIRS values showed no significant differences between before and after measurements. No significant differences were detected at echocardiographic evaluation performed before and after mydriatic administration. No adverse reaction was observed in the study population during the study., Conclusion: This is the first study that evaluated the early hemodynamic effects of mydriatic eye drops used for ROP screening by vital signs, NIRS, and echocardiographic evaluation. Mydriatic eye drops have no significant effect on early hemodynamic parameters including vital signs, NIRS, and echocardiographic findings in preterm infants. We suggest that a cautious approach for avoiding the systemic absorption of these agents may prevent the possible early systemic effects in this high-risk population., Key Points: · Mydriatic eye drops are commonly used for pupil dilatation before retinopathy of prematurity examination, and there are reports of serious adverse events caused by these drops.. · Due to the adverse events of eye drops, hemodynamic effects of these agents were investigated by clinical findings, near-infrared spectroscopy, and echocardiography.. · No significant early hemodynamic effect was observed so avoiding systemic effects may be prevented with precautions.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: To evaluate the efficacy of topical tropicamide when placed at different time intervals before or after a saline drop., Animals Studied: Eight healthy Labrador and golden retriever dogs., Procedures: The effect of 1% tropicamide on pupillary diameter (PD) was measured over 240 min when administered alone (control) and then 1 and 5 min prior to, or following, application of a saline drop, with 1-week washout between each of the five trials. Data were analyzed using repeated-measures ANOVA and Tukey post hoc test., Results: Only 6/110 pairwise comparisons among the 5 trials were statistically significant (p ≤ .035), with post-hoc analysis showing no significant differences (p ≥ .14) between the overall means of all trials. In all five trials, maximal PD was reached 30 min after tropicamide application and maintained until 210 min for 180 min (p = .0005)., Conclusions: Our results suggest that waiting 1 min between applications of different ophthalmic solutions may be sufficient for maximal drug effect. Care should be taken when extrapolating these results to other species and different ophthalmic formulations., (© 2021 American College of Veterinary Ophthalmologists.)

Purpose of the Study: Macular pigment (MP), comprising the dietary carotenoids lutein, zeaxanthin and meso-zeaxanthin, is believed to benefit eye health and vision. Numerous clinical and research devices and techniques are currently available to facilitate MP optical density (MPOD) measurement. One of those techniques, dual-wavelength fundus autofluorescence (AF) is being increasingly used for measurement of MP in the eye. There is substantial methodological variation across the published studies that have employed this technique, including in relation to the use of mydriasis, the possible influence of which does not appear to have been addressed in the literature. This prospective cross-sectional study was designed to investigate the effect of mydriasis on MP measurement quality and MPOD values obtained with dual-wavelength AF using the Heidelberg Spectralis HRA+OCT device., Materials and Methods: Twenty-one healthy participants were recruited to the study. The mean age of participants was 44.8 years (± 14.63). Pupil size and MPOD were measured in one eye for each participant, initially under natural pupil conditions and subsequently 30 minutes following instillation of one drop of 0.5% tropicamide., Results: Despite providing MPOD measurements for the majority of undilated eyes (85.7% of eyes herein), pupillary dilation resulted in statistically significant changes in MPOD ( p < .001 for central eccentricities). Our results indicate that the changes in MPOD were not uniform across the spatial profile. Marked improvements were also observed in image quality post-dilation ( p < .002 for central eccentricities)., Conclusions: This study clearly demonstrates that dual-wavelength AF measurements of MPOD in the same eye vary as a function of pupillary dilation status, with MPOD under-estimated across the entire spatial profile of MP for natural relative to dilated pupillary conditions. Mydriasis should, therefore, be used routinely for MPOD measurements using dual wavelength AF, pupil size should be reported and image quality optimized in order to ensure accurate MPOD quantification.

PRéCIS:: Small but significant decreases in optical coherence tomography angiography (OCTA)-measured circumpapillary capillary density (cpCD) were observed in healthy eyes dilated with 2.5% phenylephrine/0.5% tropicamide. Although likely clinically insignificant, ophthalmologists should consider these changes when interpreting OCTA results from dilated eyes., Purpose: The purpose of this study was to investigate the effect of pupil dilation using 2.5% phenylephrine and 0.5% tropicamide on quantitative assessment of retinal microvasculature using OCTA., Methods: OptoVue AngioVue high density (HD) and non-HD OCTA macula and optic nerve head (ONH) images were obtained at 15-minute intervals predilation and postdilation in 26 healthy participants (mean age: 40.0; 95% confidence interval=33.9, 46.1 y). Superficial macular vessel density (VD) was measured in the whole image VD and the parafoveal region VD. ONH capillary density was measured in the whole image capillary density and the cpCD region. Differences between predilation and postdilation densities were assessed using linear mixed effects models to account for within-patient correlation., Results: Instillation of dilating drops resulted in a small but statistically significant reduction in non-HD ONH whole image capillary density of 0.6%, from a mean of 45.2% (95% confidence interval=41.9%, 48.4%) to 44.6% (41.4%, 47.8%) (P=0.046). A similar reduction in non-HD ONH cpCD of 0.8% also was observed, from a mean of 49.3% (45.3%, 53.3%) to 48.5% (44.5%, 52.4%) (P=0.025). No postdilation decreases in macular VD or HD ONH capillary density were observed., Conclusions: Pupil dilation using topical 2.5% phenylephrine and 0.5% tropicamide results in a small but statistically significant reduction in non-HD ONH whole image and cpCD in healthy eyes. The observed reduction likely is not clinically significant because the observed reduction was within the previously reported range of measurement variability. Further studies should consider investigating these effects in nonhealthy eyes with glaucoma and media opacities, as well as older individuals.

Purpose: Mixed eye drops containing 0.5% tropicamide and 0.5% phenylephrine are commercially available for cycloplegic refraction. Determining the pharmacokinetics (PK) and distribution of tropicamide and phenylephrine simultaneously in ocular tissues is an important but challenging issue. Herein, we developed a sensitive and selective ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for simultaneous determination of tropicamide and phenylephrine concentrations in rabbit ocular tissues and plasma. Methods: The two analytes were extracted with ethyl acetate using etofesalamide as an internal standard and separated using a chromatographic C 8 column with isocratic elution. Mass spectrometry analysis was performed with positive electrospray ionization and data were acquired in a multiple reaction monitoring mode. Results: We validated this method over a concentration range of 5-1,600 ng/mL for tropicamide and 1-320 ng/mL for phenylephrine in ocular tissues, as well as 0.5-64 ng/mL for both compounds in plasma. Inter- and intraday precisions in all samples were both <12.9% and the accuracy was within 92.1%-108.4%. The highest concentration of tropicamide was found in aqueous humor (C max : 29430 ng/g), while was in cornea for phenylephrine (C max : 3465 ng/g). All the ocular tissues concentrations were much higher than those of blood. Conclusion: This UPLC-MS/MS method allowed us to determine the PK and distribution of tropicamide and phenylephrine in rabbit ocular tissue, which may be helpful in the future development and application of mydriatic agents.

Purpose: To study the pupillary system by combining mydriasis and multifocal pupillographic objective perimetry (mfPOP). In particular, we explored how the dynamics of recovery differ for concurrently measured direct and consensual sensitivity, response delay, and signal-to-noise ratios (SNRs) for binocular mydriasis., Methods: We recruited 26 normal participants, all with brown irides. The dichoptic mfPOP stimuli concurrently assessed 44-region/eye and both pupils. Two pre-dilation tests were followed by pairs of repeated tests at 1, 2, 4, 6, 8, 12, 24, and 48 h following dilation of both pupils with 1% tropicamide. Three subjects were retested with only the right pupil dilated. Linear models determined the independent effects of mydriasis upon the per-region and pupil measures over time., Results: Post-dilation, the per-region delays initially decreased by 16.3 ± 6.02 ms (mean ± SE) (p < 0.0001, cf. baseline of 471.1 ± 4.36 ms), then increased to slower than baseline by 17.42 ± 5.57 ms after 4 h (p < 0.002), recovering to baseline at 8 h. By comparison, per-region sensitivities (constriction amplitudes) were still reduced by - 6.20 ± 0.70 μm at 8 h (p < 0.0001, cf. baseline of 21.1 ± 0.55 μm), recovered at 24 h, but rebounded at 48 h (p = 0.005). The SNRs for sensitivities and delays both recovered by 8-12 h. Across all the data, sensitivities reduced by 2.67 ± 0.25 μm/decade of age, and delay increased by 15.4 ± 1.98 ms/decade (both p < 0.00001). Data from 3 of the 26 subjects who repeated the testing for monocular dilation found that consensual response sensitivities were larger than direct for 8 h (p < 0.018)., Conclusions: The per-region sensitivities were affected for longer than SNRs or delays. Strong early SNRs indicated proportionately lower pupil noise for larger pupil diameters. Following mydriasis with tropicamide 1%, the constriction amplitude measurements with mfPOP should be considered only after 48 h, but time-to-peak can be measured after 8-12 h.

Introduction: Cataract surgery is the most commonly performed surgery in the world, and its success depends in part on the quality of mydriasis., Purpose: To compare, for the same eye, the pupillary dilation obtained with Mydrane® (standardized intracameral solution of 0.02% tropicamide, combined with 0.31% phenylephrine and 1% lidocaine) intraoperatively versus Mydriasert® (0.28mg tropicamide insert and 5.4mg phenylephrine) with a contact time between 45 and 60 minutes in the preoperative period., Methods: Single center prospective study from November 2016 to January 2018 at the Laveran Army Instructional Hospital in Marseille. Patients referred for surgery were dilated at the preoperative consultation with Mydriasert®. The pupillary diameter after 45-60 minutes of contact with the insert was manually measured, by two different examiners, through the "iris image" tab of the Pentacam® elevation topography. Patients were dilated on the day of their cataract surgery with 0.2cc of Mydrane® injected in the anterior chamber through a paracentesis. Thirty seconds later, prior to injection of viscoelastic, an eye photograph was taken by screen capture. The pupillary diameter was evaluated by two different examiners with to the Piximeter 5.9 metrology software. The difference in pupil dilation between Mydriasert® and Mydrane® was tested with the paired series Student t-test., Results: In total, 111 eyes of 82 patients were included. Mydriasert® achieved a mean pupillary dilation of 7.21±0.79mm. The mydriasis obtained with Mydrane® averaged 6.35±0.8mm. This difference of 0.86mm was statistically significant (P<0.001) with a confidence interval of 95% [-0.97; -0.74]., Conclusion: On average, Mydrane® dilates the pupil less than Mydriasert®. However, the mydriasis obtained with Mydrane® remains comfortable for the performance of the capsulorhexis. It helps save preoperative time and affords additional anesthetic to the cataract surgery. Nevertheless, the use of Mydriasert® is beneficial when extra mydriasis is required., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: To determine effects and side effects of topical application of phenylephrine 2.5% and tropicamide 0.5% combination in preterm infants., Methods: In this prospective observational study, 60 infants undergoing retinopathy of prematurity (ROP) screening were prospectively observed. Pupillary diameter, blood pressure, heart rate, and oxygen saturation were monitored before and after up to 24 h during ROP screening examinations., Results: The mean pupillary diameter 1 h after the instillation of drops was 5.58 ± 0.75 mm for both eyes. The mean systolic and diastolic pressure and oxygen saturation of infants did not change statistically until the end of the study. The average heart rate decreased by a mean of 4.96 beats/minute from the baseline following eye drops instillation. General condition deterioration, fall in oxygen saturation and bradycardia were observed in 4 infants that already had respiratory distress syndrome., Conclusion: The phenylephrine 2.5% plus tropicamide 0.5% drop is effective and safe as mydriatic combination for retinopathy of prematurity screening. In infants with an additional systemic disease such as respiratory distress syndrome, the side effects of mydriatic drops may be more common. Such babies should be kept under close observation., Trial Registration: The trial was retrospectively registered on 28 February 2018. The ClinicalTrials.gov Identifier is NCT03448640.

Ophthalmic medications used for diagnostic or therapeutic purposes are common causes of allergic contact dermatitis around the eyes. We report a case of periocular allergic contact dermatitis due to tropicamide and phenylephrine eye drops in a 1-year-old infant., (© 2019 Wiley Periodicals, Inc.)

Tropicamide 0.02%/phenylephrine 0.31%/lidocaine 1% injectable solution (Mydrane ® ) is the first fixed-dose mydriatic/anaesthetic combination approved for intracameral use in adults undergoing cataract surgery. In a phase 3 trial in this setting, intracameral tropicamide/phenylephrine/lidocaine was at least as effective as a standard topical regimen of tropicamide plus phenylephrine in enabling successful capsulorhexis without the use of additional mydriatics. The intracameral preparation, which is administered via a single injection, provides rapid and sustained mydriasis through to the end of surgery, with recipients spending around half as long in preoperative/surgery rooms as standard topical regimen recipients in the phase 3 study. Moreover, significantly more of the intracameral than topical regimen recipients were free from pain or pressure in the eye/orbit before intraocular lens (IOL) implantation and had an IOL implanted without complications. Intracameral tropicamide/phenylephrine/lidocaine also displayed mydriatic efficacy in patients with diabetes in this trial. Overall, the preparation was generally well tolerated, with no serious adverse events leading to hospitalization or permanent vision loss. Thus, tropicamide/phenylephrine/lidocaine injectable solution is an emerging option for mydriasis/anaesthesia in adults undergoing cataract surgery.

Significance: Increasing prevalence of refractive error requires assessment of ametropia as a screening tool in children. If cycloplegia is not an option, knowledge about the increase in uncertainty for wavefront-based autorefraction is needed. The cycloplegic agent as the principal variant presents cross-reference and allows for extraction of the influence of accommodation., Purpose: The purpose of this study was to determine the repeatability, agreement, and propensity to accommodate of cycloplegic (ARc) and noncycloplegic (ARnc) wavefront-based autorefraction (ZEISS i.Profiler plus; Carl Zeiss Vision, Aalen, Germany) in children aged 2 to 15 years., Methods: In a clinical setting, three consecutive measurements were feasible for 145 eyes (OD) under both conditions. Data are described by spherical equivalent (M), horizontal or vertical astigmatic component (J0), and oblique astigmatic component (J45). In the case of M, the most positive value of the three measurements was chosen, whereas the mean was applied for astigmatic components., Results: Regarding agreement, differences for ARc minus ARnc were statistically significant: for M, 0.55 (0.55 D; mean [SD]; P < .001), that is, more hyperopic in cycloplegia; for J0, -0.03 (0.11 D; P = .002); and for J45, -0.03 D (SD, 0.09 D; P < .001). Regarding repeatability, astigmatic components showed excellent repeatability: SD < 0.11 D (ARnc) and SD < 0.09 D (ARc). The repeatability of M was SD = 0.57 D with a 95% interval of 1.49 D (ARnc). Under cycloplegia, this decreased to SD = 0.17 D (ARc) with a 95% interval of 0.50 D. The mean propensity to accommodate was 0.44 D from repeated measurements; in cycloplegia, this was reduced to 0.19 D., Conclusions: Wavefront-based refraction measurement results are highly repeatable and precise for astigmatic components. Noncycloplegic measurements of M show a systematic bias of 0.55 D. Cycloplegia reduces the propensity to accommodate by a factor of 2.4; for noncycloplegic repeated measurements, accommodation is controlled to a total interval of 1.49 D (95%). Without cycloplegia, results improve drastically when measurements are repeated.

Purpose: The aim of this study was to evaluate the factors affecting cycloplegia, as determined by pupil reactivity, in Asian children., Design: Prospective observational study., Methods: Two-hundred sixty-eight children, aged 2 to 12 years, requiring cycloplegic refraction, were recruited. Nurses instilled 2 to 3 cycles of eye drops consisting of cyclopentolate 1%, tropicamide 0.5%, and phenylephrine 2.5%, and recorded the child's level of cooperation. Optometrists recorded pupil reactivity after the last cycle. Multivariate analysis determined factors affecting pupil reactivity including age, sex, race, number of eye drop cycles, pupil sizes before and after cycloplegia, and child's cooperation during eye drops instillation., Results: The pupils in 36 children (13.4%) were found to be still reactive. On univariate analysis, children with reactive pupils also had smaller pupils after cycloplegia (6.27 ± 1.16 mm vs 7.42 ± 0.81 mm, P < 0.001). On multiple logistic regression analysis, for every 1-mm increase in the pupil size after cycloplegic eye drop administration, the odds of having reactive pupils decreases by 65% (odds ratio = 0.35, 95% confidence interval 0.25-0.51, P ≤ 0.001). Those who were uncooperative during administration of eye drops were 3.13 times more likely to have reactive pupils (95% confidence interval 1.21-8.13, P = 0.019), whereas age (P = 0.904), sex (P = 0.355), the number of cycles of eye drops (P = 0.462), and other psychological factors were not relevant in affecting pupil reactivity., Conclusions: Pupil reactivity, which was used as a measure of cycloplegia, was more likely to be affected by children's level of cooperation during instillation of eye drops, rather than age and sex. Two cycles of eye drops were as effective as 3 cycles in producing cycloplegia.

Purpose: To examine the cycloplegic and mydriatic effect of tropicamide omission from a common pediatric eye drop combination., Methods: Consecutive children examined at the Ann & Robert H. Lurie Children's Hospital of Chicago from June 8, 2017 to September 6, 2017 were enrolled prospectively. Tropicamide, cyclopentolate, and phenylephrine (TCP) was instilled in one eye; cyclopentolate and phenylephrine (CP), in the other. Spherical equivalent, maximum pupil size, and pupillary constriction in response to photostimulation were measured before and 30 minutes after instillation using an autorefractor and pupillometer. Iris pigmentation was examined as a between-subjects variable., Results: A total of 75 children 4-11 years of age were included. Mean differences in spherical equivalent between TCP and CP were not statistically significant (P = 0.95). Significant interactions between eye drop regimen and iris pigmentation were observed for pupil size (P = 0.001) and constriction percentage (P = 0.02). Among only patients with dark irides, TCP yielded slightly larger pupils (7.70 vs 7.31 mm [P < 0.001]) that were less responsive to light (5.75% vs 8.07% [P = 0.002]). All pupils dilated to ≥6.0 mm, with equivalent proportions achieving ≥7.0 mm for TCP and CP (P = 0.18)., Conclusions: TCP and CP elicited equivalent cycloplegic effects. Mydriatic differences between the regimens, although statistically significant in dark irides, were of limited clinical magnitude, and all pupils achieved sufficient dilation for funduscopy., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: Eye drop treatment routinely used to obtain mydriasis prior to fundoscopy in neonates requires repeated instillations of mydriatic agents that can lead to systemic side effects., Objectives: The aim of this study was to compare the mydriatic efficacy and tolerance of administration of phenylephrine and tropicamide via the ophthalmic insert Mydriasert® versus standard eye drop treatment in neonates., Methods: In this prospective, single-blinded, noninferiority study, 80 hospitalized neonates (age < 18 months) requiring bilateral fundus examination were randomized to receive eye drops (repeated instillations of 2.5% phenylephrine and 0.5% tropicamide) or the insert. The primary outcome was mydriasis suitable for fundoscopy 75 min after mydriatic agent introduction (T75)., Results: Mydriasis was successfully achieved in both eyes at T75 in 97.5% (n = 39/40) of the insert group patients versus 90% (n = 36/40) receiving eye drops (between-group difference 7.5%, demonstrating noninferiority). Mydriasis remained stable in 60.0% of patients (n = 24/40) in the insert group versus 15% (n = 6/40) in the eye drop group (p < 0.0001). The insert group required fewer nursing interventions than the eye drop group (p = 0.0001). Mean blood pressure were significantly higher in the insert versus the eye drop group (p < 0.0001 and p = 0.0003, respectively); mean heart rate was not significantly different between the groups (p = 0.37). In the insert group, 2 patients reported an adverse event (bradycardia, n = 1, and gastroesophageal reflux, n = 1; both appeared to be related to neonate pathology)., Conclusions: The degree of mydriasis achieved with Mydriasert® was noninferior to that obtained with eye drops. The insert appears to be safe to use in neonates without a history of increased vagal tone or gastrointestinal reflux., (© 2018 S. Karger AG, Basel.)

Objective: To assess changes in pupil size and intraocular pressure (IOP) following topical application of a 0.5% tropicamide solution in the eyes of healthy butorphanol-sedated dogs., Animals: 12 healthy adult Beagles., Procedures: In a randomized crossover study consisting of 2 treatment periods with a 1-week washout between periods, dogs received an IM injection of butorphanol (0.2 mg/kg) or an equal volume of sterile saline (0.9% NaCl) solution. For each dog, 1 drop of 0.5% tropicamide ophthalmic solution was topically instilled in one eye and 1 drop of artificial tear solution was topically instilled in the other eye 10 minutes after the IM injection and again 5 minutes later. Extent of sedation, pupil size, and IOP were evaluated from 20 minutes before to 80 minutes after the IM injection and compared among treatment combinations., Results: Butorphanol induced mild (n = 9) or moderate (3) sedation in all dogs and slightly delayed the onset of, but did not prevent, tropicamide-induced mydriasis. Butorphanol caused a significant increase in IOP, which was not exacerbated by tropicamide-induced mydriasis; however, that increase was generally not sufficient to exceed the upper limit of the IOP reference range., Conclusions and Clinical Relevance: Results indicated that butorphanol did not prevent tropicamide-induced mydriasis but did increase the IOP in ophthalmologically normal Beagles. Although the butorphanol-induced increase in IOP did not appear clinically relevant for the dogs of this study, that may not be true for dogs with glaucoma, and care should be taken when butorphanol is administered to such dogs.

Background: Intracameral Mydrane might facilitate a more streamlined cataract service and improve the patient experience. There is limited 'real-world' evidence of its use in a UK setting., Methods: As part of a local evaluation of cataract surgery using intracameral Mydrane (group 2; n=60), data were collected on intraoperative pupil size and postoperative visual acuity (VA), as well as the rate of mechanical pupil dilation, intraoperative floppy iris syndrome (IFIS) and complications. Preoperative and theatre turnaround time was recorded and patients completed a validated measure of satisfaction postoperatively. Data were compared with a previous cohort subjected to the existing standard regime of preoperative topical mydriatics (group 1; n=60)., Results: Postoperative VA was comparable between groups (0.09±0.16 vs 0.08±0.15; p=0.59). Pupil size in group 2 was 7.0±1.0 mm prior to capsulorhexis and 6.5±0.29 mm after cortical aspiration, with a smaller pupil in patients on alpha-antagonists (4.7±1.1 mm; p=0.004) at this later time point. Comparing group 2 with group 1, preoperative waiting was less (87 vs 146 min; p<0.0001) and satisfaction was higher (76.0±11.2 vs 66.3±8.6; p<0.0001), although theatre turnaround time was longer (25 min vs 22 min)., Conclusion: Intracameral mydriasis was clinically effective in most patients undergoing cataract surgery and might be associated with an improved patient experience and a more streamlined preoperative flow. Mydrane represents a licensed alternative to the off-label use of other intracameral mydriatic agents, but was not judged to be a cost-effective intervention for routine use in this particular setting., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: During cataract surgery, maintaining an adequate degree of mydriasis throughout the entire operation is critical to allow for visualisation of the capsulorhexis and the crystalline lens. Good anaesthesia is also essential for safe intraocular surgery. Mydrane® is a new injectable intracameral solution containing two mydriatics (tropicamide 0.02% and phenylephrine 0.31%) and one anaesthetic (lidocaine 1%) that was developed as an alternative to the conventional topical pre-operative mydriatics used in cataract surgery. This study aimed to estimate the budget impact across a one year time frame using Mydrane® instead of topical dilating eye drops, for a UK hospital performing 3,000 cataract operations a year., Methods: A budget impact model (BIM) was developed to compare the economic outcomes associated with the use of Mydrane® versus topical drops (tropicamide 0.5% and phenylephrine 10%) in patients undergoing cataract surgery in a UK hospital. The outcomes of interest included costs and resource use (e.g. clinician time, mydriasis failures, operating room time, number of patients per vial of therapy etc.) associated with management of mydriasis in patients undergoing cataract surgery. All model inputs considered the UK hospital perspective without social or geographical variables. Deterministic sensitivity analyses were also performed to assess the model uncertainty., Results: Introduction of Mydrane® is associated with a cost saving of £6,251 over 3,000 cataract surgeries in one year. The acquisition costs of the Mydrane® (£18,000 by year vs. £3,330 for eye drops) were balanced by substantial reductions in mainly nurses' costs and time, plus a smaller contribution from savings in surgeons' costs (£20,511) and lower costs associated with auxiliary dilation (£410 due to avoidance of additional dilation methods). Results of the sensitivity analyses confirmed the robustness of the model to the variation of inputs. Except for the duration of one session of eye drop instillation and the cost of Mydrane®, Mydrane® achieved an incremental cost gain compared to tropicamide/phenylephrine eye drops., Conclusions: Despite a higher acquisition cost of Mydrane®, the budget impact of Mydrane® on hospital budgets is neutral. Mydrane® offers a promising alternative to traditional regimes using eye drops, allowing for a better patient flow and optimisation of the surgery schedule with neutral budget impact.

The aim of the present paper was the development of semi-solid (hydrogels) and solid (film) ophthalmic formulations for the controlled release of two mydriatics: phenylephrine and tropicamide. The formulations - based on polyvinylalcohol and hyaluronic acid - were characterized, and release studies were performed with three different in vitro set-ups, i.e. Franz-type diffusion cell, vial method and inclined plane; for comparison, a solution and a commercial insert, both clinically used to induce mydriasis, were evaluated. Both gels and film allowed for a controlled release of drugs, appearing a useful alternative for mydriatics administration. However, the release kinetic was significantly influenced by the method used, highlighting the need for optimization and standardization of in vitro models for the evaluation of drug release from ophthalmic dosage forms.

Purpose: To study the time course (onset, time and duration of maximal cycloplegia, and the full duration) of cycloplegic action of 1% Cyclopentolate - 1% Tropicamide., Methods: Seventy-seven students, aged 15-24 years were purposively sampled from the University of Cape Coast and Cape Coast Technical Institute. Subjective near addition (ADD) determination and pupil diameter measurement before and after a drop of the test agent (1% Cyclopentolate - 1% Tropicamide combination in the right eye) and the control (1% Cyclopentolate in the left eye) were performed. Measurements of subjective near ADD and pupil diameter were made after the initial reading at 5 minutes interval for the first hour and every 30 minutes for the next 7 hours for each participant. Time of onset, time of peak cycloplegia, duration of peak cycloplegia and duration of total cycloplegic effect was indirectly determined., Results: 1% Cyclopentolate - 1% Tropicamide combination had rapid onset of cycloplegia (5-10 minutes), shorter time of maximal cycloplegia (55 versus 90 minutes), and recovery (7 versus ≥ 8hours) in the majority (79.2%) of subjects., Conclusion: Cyclopentolate -Tropicamide combination was comparable to Cyclopentolate in depth of cycloplegia produced, and clinically superior to 1% Cyclopentolate in rapidity of cycloplegic onset, time of maximal cycloplegia and recovery from cycloplegia.

Purpose: Patients are usually advised to wait 5 minutes between eye drops. This delay supposedly allows the first drop not to be washed out by the second one, thereby increasing the combined effect. However, in the only experimental study conducted in humans on the concurrent administration of two different eye drops, the authors concluded that a 10-minute time interval between eye drops did not increase their combined effect. Our study was designed to address this puzzling observation., Methods: Using digital photographs shot in photopic conditions in 40 eyes of 20 healthy volunteers, we compared relative pupil surface (i.e., pupil to iris surface area ratios) before and after the administration of one drop of 10% phenylephrine and one drop of 0.5% tropicamide either immediately or after a 5-minute time interval., Results: Waiting 5 minutes yielded a 5.6% relative pupil surface gain (observer 1: P = .003, observer 2: P = .005) indicating an additional combined effect with a 5-minute time interval., Conclusions: These results show a detectable additive effect that is probably the result of methodological refinements including the challenging of the mydriasis by photopic conditions and the use of pupil and iris surface areas, which may show differences that would be undetectable in terms of diameter.

Purpose: To compare the quality of fundus photographs taken before and after instillation of one drop of tropicamide., Methods: The 45º fundus photographs were taken with a non-mydriatic fundus camera in three conditions of the pupil; pre-mydriatic, 10 minutes after one drop of tropicamide, and fully dilated. Two photographs were taken in each condition; one centered on the macula and the other on the optic disc. Two vitreoretinal specialists graded the images., Results: A total of 1768 fundus photographs of 149 diabetic patients with dark irides were included. There were more ungradable images (38.1% and 50.3%, graders 1 and 2, respectively) in the non-mydriatic state than partially- (4.6% and 11.5%) or fully-dilated (15.4% and 10.0%) conditions (p < 0.001, both graders). Partially and fully dilated states had similar rates of ungradable images (p = 0.56 and p = 0.54, graders 1 and 2, respectively). Test-retest reliability (repeatability) was 92.5% and 74.3% for the two graders, respectively. Inter-grader agreement was moderate (Kappa = 0.50)., Conclusion: Non-mydriatic fundus photographs have a high rate of ungradable images in patients with dark irides. Instillation of only one drop of tropicamide improves the quality of fundus photographs, which is not furthered by adding more drops. This strategy can be used in tele-ophthalmology programs.

Aims: Tropicamide is a mydriatic drug used as eye-drops for diagnostic or therapeutic purposes. From 2013, a diverted use by intravenous route has been suspected in Eastern Europe in opioids users. To date, no signal of misuse has been identified in France. The aims of this study were to investigate any early signals of a diverted use of tropicamide eye drops and to collect information regarding motives for the misuse and tropicamide-induced effects., Methods: Information was obtained at three levels: (1) at regional level (Midi-Pyrénées area), from reimbursement data and pharmacists' reports on suspicious requests; (2) at national level: from reimbursement data and prescriptions suggesting possible abuse from the OSIAP (Ordonnances Suspectes, Indicateur d'Abus Possible) survey; and (3) at international level: from VigiBase ® reports and Web sources. Beta-blocker eye-drops were used as comparators., Results: In France, in 2014-2015, 17 (0.91%, 95% CI [0.53-1.46%]) falsified prescriptions involving tropicamide were identified in the OSIAP survey (compared with 0%, 95% CI [0-0.19%] for beta-blockers). Moreover, 37 other suspicious prescriptions were presented in 2015 (notified in 2016). In Midi-Pyrénées, seven patients aged 35-49 were reimbursed for 19-45 vials of 10 ml, in a year. Since September 2014, the regional Addictovigilance Centre has received 91 notifications of suspicious requests to obtain tropicamide. In VigiBase ® , two cases were identified but none in France. An increased interest in tropicamide-related Internet searches was observed from Russia and Ukraine., Conclusions: These results represent the first early warnings of a tropicamide diverted use in France. Tropicamide abusers would seek euphoria or hallucinations. The high doses involved in intravenous administration could lead to serious complications., (© 2017 The British Pharmacological Society.)

Purpose: To evaluate the effectiveness of a cycloplegic regimen using 0.5% tropicamide and 0.5% phenylephrine (Tropherine, Hanmi Pharm), in addition to 1% cyclopentolate, in hyperopic children., Methods: The medical records of hyperopic patients below the age of 14 years who had undergone cycloplegic retinoscopy were retrospectively reviewed. Cycloplegic refractions were performed using one of two cycloplegic regimens. Regimen 1 was a Tropherine-added regimen comprising the administration of one drop of 1% cyclopentolate followed by two to three drops of Tropherine added at 15-minute intervals. Regimen 2 was a cyclopentolate-only regimen comprising the administration of three to four drops of 1% cyclopentolate at 15-minute intervals. The mean difference between noncycloplegic and cycloplegic refraction was compared between the two regimens., Results: A total of 308 eyes of 308 hyperopic children were included. The mean difference (±standard deviation) in the spherical equivalent (SE) between cycloplegic and noncycloplegic refraction was significantly larger in regimen 2 than in regimen 1, with values of +1.70 ± 1.03 diopters (D) and +1.25 ± 0.89 D, respectively (p=0.001). The SE change after cycloplegia was significantly different between the two regimens only in patients aged 5 years or younger (p=0.001), particularly in those with high hyperopia with an SE ≥5 D (p=0.005) or fully accommodative esotropia (p=0.009). There was no significant difference between the two regimens in patients older than 5 years, regardless of the presence of high hyperopia or fully accommodative esotropia., Conclusions: The Tropherine-added regimen exerted a weaker cycloplegic effect than the cyclopentolate-only regimen, particularly in children under the age of 5 years with high hyperopia or fully accommodative esotropia. However, the difference in refraction between the two regimens was small. A Tropherine-added regimen can be effective in hyperopic children, with less associated discomfort than the instillation of cyclopentolate., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2017 The Korean Ophthalmological Society)

Purpose: To evaluate the safety and tolerability of a single intracameral administration of a combined mydriatic (tropicamide and phenylephrine) and anesthetic (lidocaine) formulation (Mydrane) with or without rinsing., Setting: Iris Pharma, La Gaude, France., Design: Experimental study., Methods: Sixty pigmented rabbits received 100 μL or 200 μL of the combination product or a placebo (sodium chloride 0.9%) by intracameral injection. For the combination product, separate groups were included with and without rinsing after administration. From day 1 day to day 7, assessments included general clinical and ocular observations, pupil diameter measurements, corneal assessments, confocal microscopy, and electroretinography (ERG). Necropsy examinations were performed at study completion at day 8., Results: Rapid mydriasis, stable 24 minutes after injection and returning to baseline levels by day 1, was induced in all groups that received the combination mydriatic and anesthetic drug. Rinsing had no effect. The combination product induced no adverse effects on the anterior or posterior segment of the eye (ie, no increased corneal thickness and endothelial cell loss, no abnormalities in ERG). Slitlamp examination showed slightly increased anterior chamber inflammation with rinsing in both the study group and placebo group. This observation was not confirmed by aqueous flare examination. No toxic effects of the products were found on histological evaluation., Conclusion: The combination mydriatic and anesthetic drug administered to pigmented rabbits as a single intracameral injection at volumes of 100 μL and 200 μL was well tolerated with no ocular adverse effects and no effect on the corneal endothelium., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: Pupillary dilatation with three types of eye drops is used regularly in the clinic; however, a mixture of these drops in a single bottle may be more beneficial in reducing workloads and resources. This study compared the efficacy in pupillary dilatation between two protocols of dilating drop instillation., Methods: This prospective, randomized, comparative study included 30 eligible Thai patients. The patients randomly received preoperative pupillary dilatations by either the conventional protocol (1% tropicamide (T), 10% phenylephrine (P) and 0.1% diclofenac (D) in three separate bottles) or the fixed combination (TPD) protocol which had the three types of eye drops mixed in a single bottle in a ratio of 4:3:3. The chi-square test and independent t-test were used to analyze the data., Results: The conventional protocol group and TPD protocol group each had 15 patients. Sixty minutes after the initial instillation, all patients in the TPD protocol and 13 patients (86.7%) in conventional protocol achieved at least 6mm in the shortest diameter. The mydriatic rate between protocols showed no difference. In patients who received the TPD protocol, the systemic effects on the mean arterial blood pressure and pulse rate decreased over time., Conclusion: The mixture of tropicamide, phenylephrine and diclofenac had a comparable efficacy for a pupillary dilatation to the conventional dilating drops in separate bottles. The systemic complications on blood pressure and arterial pulse of the TPD mixture were less than the conventional protocol., Trial Registration: TCTR20130325001., (Copyright © 2016 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose: Comparison of the efficacy of tropicamide eyedrops to the combination of 0.5% tropicamide and 5% phenylephrine eyedrops in order to achieve a proper dilation in premature infants undergoing screening for retinopathy of prematurity., Methods: A prospective, randomized, double-blind study was conducted to compare the efficacy of two mydriatic regimens: one regimen consisting of three drops of 0.5% tropicamide (TTT regimen), the other regimen consisting of one drop of 5% phenylephrine and two drops of 0.5% tropicamide (PTT regimen). Thirty premature infants were enrolled and received both mydriatic regimens: one regimen in each eye. Outcomes were pupil dilation evaluated by the percentage of pupil diameter over cornea diameter, the percentage of pupil surface over cornea surface and the quality of the eye fundus examination., Results: The percentage of pupil diameter over cornea diameter was 47.3% (±8.7) with the TTT regimen and 65.9% (±8.8) with the PTT regimen (p < 0.0001). The percentage of pupil surface over cornea surface was 23.1% (±8.3) with the TTT regimen and 43.8% (±7.3) with the PTT regimen (p < 0.0001). Thus, the pupil surface area was 1.9 times greater with the PTT than with the TTT regimen. Visualization of the retinal periphery was possible for 30 of 30 eyes dilated with the PTT regimen and for 16 of 30 eyes dilated with the TTT regimen (p < 0.0001)., Conclusion: The dilated pupil surface area for the combination of 5% phenylephrine and 0.5% tropicamide was almost twice that for 0.5% tropicamide eyedrops alone and provided significantly superior quality of the eye fundus examination., (© 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Objectives: The aim of this study was to evaluate the effect of topical tropicamide at two concentrations (0.5% and 1.0%) on the Schirmer tear test (STT) results in clinically normal cats., Methods: Twenty-four adult domestic shorthair cats were randomly assigned to three groups. In all three groups, ophthalmic solutions were instilled in a randomly selected eye and the opposite eye served as the control. In groups 1, 2 and 3 one drop of 0.5% tropicamide, 1.0% tropicamide and distilled water was used, respectively. Tear production in both eyes was tested 30 and 60 mins after instillation in all three groups., Results: Baseline mean ± SEM STT values for the treated eyes in groups 1, 2 and 3 were 13.37 ± 2.91 mm/min, 10.87 ± 1.39 mm/min and 11.37 ± 1.65 mm/min, respectively. Thirty minutes after the drug instillation in the treated eye, mean ± SEM STT values in groups 1, 2 and 3 were 4.87 ± 3.05 mm/min, 2.00 ± 0.84 mm/min and 11.25 ± 1.81 mm/min, respectively. The mean ± SEM STT levels of the treated eye after 60 mins were 3.75 ± 1.87 mm/min, 0.5 ± 0.37 mm/min and 11.42 ± 1.78 mm/min in groups 1, 2 and 3, respectively., Conclusions and Relevance: Use of 0.5% topical tropicamide, instead of 1.0% tropicamide, as a mydriatic agent, can be recommended in cats. Tear production measurement should be performed prior to the administration of tropicamide, regardless of the concentration of this drug., (© The Author(s) 2015.)

Aim: Eyedroppers deliver medication volumes exceeding conjunctival absorptive capacity, causing spillage and risking ocular/systemic complications. We evaluated piezoelectric microdosing. Results/methodology: Subjects (n = 102) received precision microdroplet delivery of phenylephrine (2.5%) and tropicamide (1.0%): 1 × 1.5 μl, 1 × 6 μl or 2 × 3 μl of each (randomized 1:1:1), into one eye. Contralateral eyes received eyedropper doses of both drugs. Outcomes were pupil dilation (0-60 min) and patient satisfaction. Six-microliter microdosing achieved comparable, and 2 × 3 μl met/exceeded dilation speed and magnitude versus eyedropper. Separately, participants preferred piezoelectric saline self-delivery to eyedroppers, reporting better head-positioning comfort, reduced tearing/overflow and increased likelihood of adhering to ocular medication regimens., Conclusion: Piezoelectric microdosing achieves comparable effects as eyedroppers delivering 4-17-fold larger doses. Microdosing may enhance patient adherence to ocular medication regimens while minimizing side effects.

Purpose: The aim of this study was to investigate the time-course of changes in choroidal thickness (ChT) following complete mydriasis induced by compound tropicamide., Methods: ChT was measured by OCT with the enhanced-depth imaging technique (Spectralis HRA+OCT, Heidelberg Engineering, Germany) at nine locations of the fundus: subfoveal ChT (SFChT) and ChT at 1 mm and 3 mm from the fovea in four quadrants. Mydriasis was induced with compound tropicamide (0.5% tropicamide plus 0.5% phenylephrine hydrochloride, three doses at 5-minute intervals). Measurements were conducted prior to the instillation and at 0, 30, and 60 min following complete mydriasis. Results at different time-points were compared using repeated-measures ANOVA to investigate the time-course of the changes., Results: Thirty-nine subjects (mean age 11.9±2 years; 16 males and 23 females) were enrolled in the study. Compound tropicamide resulted in a statistically significant decrease in SFChT at 0, 30, and 60 min after complete mydriasis, as compared to baseline (-5±4 μm, -12±4 μm, and -13±4 μm, respectively; all P<0.0001). No significant changes were detected in the parafoveal choroid except at 1 mm temporal (T1mm) and nasal (N1mm) to the fovea at 30 and 60 min (T1mm: -6±4 μm and -7±5 μm at 30 and 60 min; N1mm: -6±4 μm and -7±5 μm at 30 and 60 min, respectively; all P<0.0001). Repeated-measures ANOVA showed a significant interaction between the time after complete mydriasis and the effect of the mydriasis agent., Conclusions: Complete mydriasis induced by compound tropicamide led to choroidal thinning, and the magnitude varied over time., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To evaluate the effect of corneal crosslinking (CXL) with ultraviolet A (UVA) irradiation on pupil response to tropicamide 0.5% instillation., Methods: This prospective interventional study enrolled 17 patients (19 eyes) with progressive keratoconus who underwent CXL with UVA irradiation. Central corneal thickness (CCT) was evaluated with the use of anterior segment optical coherence tomography (Visante OCT 3.0). Pupil diameter was measured with the use of Colvard infrared pupillometer before the instillation of tropicamide 0.5% and after the instillation of tropicamide every 5 minutes for total duration of 30 minutes. Corneal epithelial integrity was examined with the use of fluorescein dye staining. Measurements were performed 1 day preoperatively and 1 month postoperatively, with emphasis on simulating the same light conditions regarding the pupil measurements., Results: No intraoperative or postoperative complications were observed in any of the patients. Mean CCT decreased significantly (p&lt;0.001) 1 month postoperatively. Mean postoperative pupil size did not change significantly at any time point compared to the mean preoperative measurements., Conclusions: The CXL procedure seems not to impair effectiveness of topical drugs, using pupil size measurements after tropicamide 0.5% instillation.

PurposeTo ascertain the risk of angle closure glaucoma associated with mydriasis in the Northern Ireland Diabetic Retinopathy Screening Programme.MethodsA retrospective case note review was carried out, cross referencing hospital records with those of the screening programme, to identify episodes of angle closure glaucoma, which occurred within 14 days of a retinopathy screening episode involving pharmacological mydriasis.ResultsThree cases of angle closure following mydriasis for screening were identified. The incidence of angle closure within the screening programme was calculated to be 1 in 31 755 patients dilated or 0.75 patients per year.ConclusionAngle closure is a rare complication of mydriasis used in photographic screening for diabetic retinopathy. We advocate the provision of clear instructions to patients in screening programmes on when and how to access emergency ophthalmic care following dilation to prevent loss of vision in this rare event.

Background/aims: To compare the efficacy and safety of intracameral (IC) administration at the beginning of cataract surgery, of Mydrane, a standardised ophthalmic combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1%, to a standard topical regimen., Methods: In this international phase III, prospective, randomised study, the selected eye of 555 patients undergoing phacoemulsification with intraocular lens (IOL) implantation received 200 μL of Mydrane (Mydrane group) just after the first incision or a topical regimen of one drop each of tropicamide 0.5% and phenylephrine 10% repeated three times (reference group). The primary efficacy variable was achievement of capsulorhexis without additional mydriatics. The non-inferiority of Mydrane to the topical regimen was tested. The main outcome measures were pupil size, patient perception of ocular discomfort and safety., Results: Capsulorhexis without additional mydriatics was performed in 98.9% of patients and 94.7% in the Mydrane and reference groups, respectively. Both groups achieved adequate mydriasis (>7 mm) during capsulorhexis, phacoemulsification and IOL insertion. IOL insertion was classified as 'routine' in a statistically greater number of eyes in the Mydrane group compared with the reference group (p=0.047). Patients in the Mydrane group reported statistically greater comfort than the reference group before IOL insertion (p=0.034). Safety data were similar between groups., Conclusions: Mydrane is an effective and safe alternative to standard eye drops for initiating and maintaining intraoperative mydriasis and analgesia. Patients who received IC Mydrane were significantly more comfortable before IOL insertion than the reference group. Surgeons found IOL insertion less technically challenging with IC Mydrane., Trial Registration Number: NCT02101359; Results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Purpose: To investigate the relationship between angle configuration and diagnostic provocation tests such as the mydriatic provocative test (MPT) and the dark room prone provocative test (DRPPT)., Materials and Methods: Seventy eyes of 70 consecutive patients with primary angle closure suspect, primary angle closure, or primary angle closure glaucoma were included. The anterior chamber depth, angle opening distance 500, trabecular-iris space area 500, and iris thickness (IT) were quantitatively determined by anterior segment optical coherence tomography, and the MPT and DRPPT were used to investigate intraocular pressure variations., Results: Seven eyes were positive and 3 eyes were suspected positive, using the MPT, whereas 10 eyes were positive and 7 eyes were suspected positive using the DRPPT. The anterior chamber depth and angle opening distance 500 of the positive and suspected positive groups (positive group), using the MPT, were significantly less than those of the negative group (P=0.013, P=0.013, respectively). IT of the positive group, using the MPT, was significantly greater than the negative group, using the same test (P=0.003). The trabecular-iris space area 500 of the positive group was significantly less than the negative group, using both the MPT (P<0.001) and the DRPPT (P=0.004)., Conclusions: Eyes from the positive group, using the MPT, contained a shallower anterior chamber, narrower angle, and greater IT than those from the negative group. These results suggested that the MPT results better correlated with the anterior chamber angle configuration in eyes with primary angle closure, than the results using the DRPPT.

Therapeutic soft contact lenses (TSCLs) are frequently used to support or protect the cornea during healing. Our aim was to quantitatively evaluate the efficacy of topical medications in TSCL-fitted dogs and determine whether it is affected by the presence of TSCLs. In Phase I, pupil diameter was measured in eyes treated with tropicamide and in eyes covered with TSCLs and then treated with tropicamide, with 1-week intervals between sessions. In Phase II, intraocular pressure (IOP) was measured in uncovered and TSCL-covered eyes treated with latanoprost, with 1-week intervals between sessions. Tropicamide caused significant mydriasis in both uncovered and TSCL-covered eyes (P = 0.005). On the other hand, latanoprost caused a significant decrease in IOP when applied to uncovered eyes (P = 0.002), but had no significant effect on IOP when applied to TSCL-covered eyes (P = 0.7). As we used the same dogs and identical TSCLs throughout the study, we conclude that the different outcomes of the two drugs are due to properties of the drugs themselves, or their formulations, affecting their interaction with the TSCLs. The clinical efficacy of topical drugs applied to TSCL-covered eyes may have to be determined for each drug and/or formulation., (© 2015 John Wiley & Sons Ltd.)

Purpose: To determine the effect of cycloplegia on corneal thickness, corneal curvature, anterior chamber depth (ACD), angle-to-angle (ATA) and white-to-white (WTW) distances, and axial length (AL)., Methods: Changes in corneal thickness, corneal curvature, ACD, ATA and WTW distances, and AL with and without cycloplegia were analyzed in 31 eyes of 31 young myopic adults, aged 26.4 ± 3.0 years. Pentacam was used to measure the corneal thickness, corneal volume, and corneal curvatures. Visante optical coherent tomography (OCT) measured corneal thickness, ATA distance, ACD, and pupil size. The AL and WTW distance were measured using IOLMaster., Results: Cycloplegia induced significant flattening of corneal curvatures (p = 0.019, 0.001, and 0.003 for anterior sagittal, posterior tangential, and posterior sagittal curvatures, respectively). The difference in the posterior corneal curvature was greater in corneas with steeper posterior curvatures. Cycloplegia also induced significant deepening of ACD (0.08 ± 0.06, p < 0.001) and widening of both WTW (0.42 ± 0.43, p < 0.001) and ATA (0.08 ± 0.17, p = 0.015) distances. The cycloplegia-related increase in the ATA distance correlated negatively with AL (r = -0.361, p = 0.046), whereas the cycloplegia-related increase in WTW distance correlated weakly with the increase in ACD (r = 0.347, p = 0.056) but not with AL. The AL did not change with cycloplegia. Pentacam measured a slightly thicker cornea than OCT (p = 0.002). Both Pentacam and OCT detected a significant increase in corneal thickness of 4 μm, which could be attributed to reflex tearing, after cycloplegia., Conclusions: Cycloplegia resulted in deeper ACD, greater ATA distance, and flatter corneal curvatures. Surgeons should be aware of these cycloplegia-related alterations for more accurate phakic/functional intraocular lens selection and better refraction results.

Objectives: To investigate the presence, nature and relationship to age, sex, ethnicity and body mass index (BMI) of adverse reactions following routine cycloplegic eye drops in children., Design: Prospective observational cohort study., Setting: Ophthalmology outpatient clinic Dutch metropolitan hospital; February, March and April 2009., Participants: Children aged 3-14-year-old children receiving two drops of cyclopentolate 1% (C+C) or one drop of cyclopentolate 1% and one drop of tropicamide 1% (C+T). Patients were categorised by age (3-6, 7-10 and 11-14 years), sex, ethnicity and body mass index (BMI) (low, normal or high)., Outcome Measures: Rate and nature of adverse reactions reported at 45 min following treatment. Crude and adjusted ORs for reporting an adverse reaction using stepwise regression analysis with BMI, age, ethnicity and sex., Results: 912 of 915 eligible patients participated (99.7%). Adverse reactions were reported for C+C in 10.3% and in C+T in 4.8% (42/408 and 24/504, p=0.002), respectively. Central effects were present in 95% in C+C and in 92% in C+T. Compared to C+T, an increased risk was present in C+C (crude OR 2.3 (1.4 to 3.9), p=0.002). Forward adjustment showed BMI to be an influencing factor in treatment (OR 3.1 (1.7 to 5.6), p<0.001). In a multivariate model, a dose of cyclopentolate remained associated with adverse reactions. Analysis per BMI and regime and age category and regime, indicated associations with low BMI (OR C+C 21.4 (6.7 to 67.96), p<0.001, respectively, C+T 5.2 (2.1 to 12.8), p<0.001) and young age (OR C+C 8.1 (2.7 to 24.8), p<0.001)., Conclusions: Adverse reactions were common and almost exclusively involved the central nervous system. Both presence and severity were associated with repeated instillation of cyclopentolate 1%, low BMI and young age. In specific paediatric populations, a single dose of cyclopentolate must be considered. Vital function monitoring facilities are advisable. Adjustment of guidelines is recommended., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: The intravenous (IV) injection of tropicamide for non-clinical purposes is a new and widespread drug trend. The aim of this study is to provide the first literature review on the topic., Methods: Relevant literature was identified through a search of MEDLINE, Psycinfo, Google Scholar, conference proceedings and select citations., Results: Cases of tropicamide (IV) injection have been reported in Russia, Italy, Turkey and Kazakhstan. This phenomenon is mainly secondary to primary opioid (especially heroin) addiction. Several key factors can be associated with its rapid diffusion: (i) enhancement of the 'positive' effects of heroin; (ii) decrease and delay of heroin withdrawal symptoms; (iii) easy availability; (iv) low costs; (v) fast effects; and (vi) visibility of self-reported experiences on Internet. Acute tropicamide intoxications can lead to anticholinergic syndrome, hyperthermia, tremors and convulsions. Chronic tropicamide-related problems include cardiovascular toxicity, psychosis, renal or liver failures, severe weight loss and infections. Fatalities due to tropicamide IV injection have been reported in non evidence-based/peer-reviewed sources, such as drug fora, websites and media news., Conclusions: Tropicamide IV injections represent a serious health risk. Specific prevention programmes should be implemented for the general population as well as for the high-risk population of polydrug abusers., (Copyright © 2015 John Wiley & Sons, Ltd.)

Purpose: To compare the efficacy in pupil dilation and degree of discomfort between topical instillation of mydriatic drops and gel., Methods: The study included 60 patients with no previous ocular history of trauma and surgery. One eye was dilated with two drops (tropicamide 0.5% and phenylephrine 10%), and the other with one drop of gel (tropicamide 0.5%+phenylephrine 5%). Pupil size was measured by a Colvard pupillometer at baseline and 5, 15, 30, and 45 min following instillation. Pain upon instillation was measured by visual analog scale (VAS)., Results: There was no difference in pupil size at baseline. Use of the gel achieved greater mydriasis than drops (P=0.01), and was also associated with lower pain scores (P=0.003). In diabetic patients, pupil size was smaller at baseline and following instillation of drops and gel. Use of the gel achieved an even greater degree of pupil dilation in this subset of patients than drops (P=0.019)., Conclusions: Gel formulation achieved significantly greater pupil dilation than drops, despite a lower concentration of phenylephrine, and was also associated with significantly lower patient discomfort. This study is the first report of improved mydriatic efficacy in diabetic patients.

Purpose: To investigate the change in pre- and post-dilation anterior segment parameters and intraocular pressure (IOP) of patients with and without pseudoexfoliation, after topical application of phenylephrine HCl 10% and tropicamide 1%., Materials and Methods: Totally 129 eyes of 129 patients were included in the study. Of the 129 eyes; 31 had pseudoexfoliation syndrome (PXS), 37 had pseudoexfoliation glaucoma (PXG), 31 eyes were the fellow eyes of subjects with unilateral pseudoexfoliation syndrome (subclinical PXS) and 30 eyes were the eyes of subjects without PXS (controls). Patients underwent Pentacam analysis and IOP measurement before and after dilation. The changes in IOP, anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA), central corneal thickness (CCT) and pupillary diameter (PD) were investigated 30 min after the application of mydriatic agents., Results: The mean change of IOP in eyes with PXS, in eyes with PXG, in eyes with subclinical PXS and eyes of control subjects were 1.45 ± 2.03 mmhg, 0.27 ± 2.25 mmhg, -0.35 ± 1.58 mmHg and -1.06 ± 1.59mmHg, respectively. Post-dilation IOP values were lower (p = 0.001) in eyes of controls but higher (p < 0.001) in eyes of PXS than the pre-dilation levels. All patients exhibited statistically significant increase in ACD, ACV and PD after the dilation procedure (p < 0.001). Additionally, post dilation CCT values were significantly lower than pre-dilation values in all groups; the difference was statistically significant only for eyes with PXG, eyes with subclinical PXS and eyes of controls., Conclusion: Eyes with PXS had a higher tendency of IOP elevation after pupillary dilation. Eyes with subclinical PXS, however, exhibited a minor increase in IOP, reflecting the asymmetrical character of the disease. Anti-glaucoma medications may have blunted any IOP elevation induced by pupillary dilation in eyes with PXG.

Purpose: This study aimed at investigating serious side effects of the pupillary dilation protocol used in Caen University Hospital for the screening of retinopathy of prematurity. This protocol includes one drop of phenylephrine 5% and two drops of tropicamide 0.5% instilled at a 5-minute interval., Patients and Methods: This retrospective study included all premature infants with a birth weight less than or equal to 1500 g and/or a gestational age less than or equal to 30 gestational weeks, hospitalized in the neonatal intensive care unit of Caen University Medical Center, having ocular fundus examinations for retinopathy of prematurity screening between 2009 and 2014. The medical records of patients who died or developed necrotizing enterocolitis were reviewed to analyze the imputability of the two eye drops used for pupil dilation., Results: Five-hundred and twelve infants were included, corresponding to 1033 ocular fundus examinations. No case of death could be ascribed to the use of eye drops. Two cases of necrotizing enterocolitis could be ascribed to the use of tropicamide with a doubtful and plausible intrinsic imputability according to French imputability criteria., Conclusion: The pupillary dilation protocol used in Caen University Hospital for screening of retinopathy of prematurity might be implicated in two cases of necrotizing enterocolitis with an uncertain imputability of tropicamide 0.5% eye drops. No serious side effect could be ascribed to the use of phenylephrine 5% eye drops in this study., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Purpose: To observe and compare the effects of pupil dilation between Mydrin-P and compound tropicamide in the screening of retinopathy of prematurity., Methods: The right eyes of premature infants received My- drin-P eye drops as the treatment group, whereas the left eyes were administered with compound tropicamide as the control group. The eye drops were delivered every 5 min for three times. The pupil size was observed and recorded at 10, 15, and 20 min after administering mydriasis., Results: The mean pupil diameter did not significantly differ between the treatment and control groups at 10 (6.24 ± 0.72 mm vs. 6.24 ± 0.68 mm, t = 0.00, P = 1.00), 15 (6.83 ± 0.55 mm vs. 6.78 ± 0.54 mm, t = 1.75, P = 0.083) or 20 min (7.22 ± 0.40 mm vs. 7.15 ± 0.50 mm, t = 1.62, P = 0.109), respectively. How- ever, the mean pupil size at any two time points significantly differed in both groups (all P < 0.001)., Conclusion: Both Mydrin-P and compound tropicamide exert similar clinical efficacy in the screening of retinopathy of pre- maturity. The most appropriate time for screening was at 20 min after mydriasis.

Purpose: To evaluate pupil dilation with intra-cameral injection of preservative-free lidocaine 1% (ICL) versus topical eye midriatics during phacoemulsification., Methods: This case-control study included 40 patients with similar bilateral senile cataract scheduled for phacoemulsification and intraocular lens (IOL) implantation. patient's first eye received topical midriatic eye drops as control group and next eye operated by intra cameral preservative free lidocaine 1% without any preoperative or intraoperative midriatics. We did not add epinephrine to the irrigating solution in either group. The first eyes received 3 drops of cyclopentolate 1% and tropicamide 1% each 5 minutes, with first dose 60 minutes before surgery. The horizontal pupil diameter was measured before and after pupil dilation using the same caliper with operation microscope total surgical time was recorded in both groups., Results: Patients included 20 male and 20 female with mean age of 72 and 70.9 years old .4 patients were diabetic and 11 cases had pseudo-exfoliation. Pupil diameter increased in both case and control groups significantly (P value<0.0) but the difference between mean increase in pupil size wasn't significantly different. Mean increase in pupil size was significantly greater in patients without pseudo-exfoliation (4.10 mm vs 3.85 mm, independent t test, P<0.05). There was no significant difference between diabetic and non- diabetic patients regarding of pre- and post-injection diameter of the pupil., Conclusion: Intra-cameral preservative-free lidocaine 1% supply adequate midriasis during cataract surgery by itself.

Purpose: To explore short-term refractive and ocular parameter changes and their correlations after cycloplegia with tropicamide., Methods: This study prospectively enrolled 114 right eyes of 114 participants (mean [±SD] age, 9.1 [±2.8] years). Spherical equivalent of refractive error (SER), axial length (AL), corneal curvature (CC), and anterior chamber depth (ACD) were measured before and after 30 minutes from instillation of 0.4% tropicamide. A partial optical coherence interferometry (Zeiss IOLMaster) was used for ocular parameter measurement. Refractive change and ocular parameter changes after cycloplegia and their correlations were evaluated., Results: Spherical equivalent of refractive error, AL, and ACD all positively shifted significantly at 30 minutes after application of 0.4% tropicamide (p < 0.0001 for each parameter measured). After cycloplegia, 28 eyes (24.6%) had a hyperopic shift of more than 0.25 diopters (D), 3 eyes (2.6%) had a myopic shift of more than 0.25 D, and 83 eyes (72.8%) had their SER changes within -0.25 to 0.25 D. The mean, maximum, and minimum keratometric values all decreased (p = 0.005, 0.03, and 0.05, respectively), whereas corneal astigmatism did not change significantly. The changes in AL, ACD, or mean keratometric values contributed little to the refractive changes after cycloplegia by tropicamide (p > 0.05, pr ≤ 0.01 for all values)., Conclusions: Spherical equivalent of refractive error, AL, and ACD all positively shifted after cycloplegia with tropicamide. Corneal curvature became flattened after cycloplegia with tropicamide, but the corneal astigmatism did not change significantly. Refractive changes did not correlate with changes in AL, ACD, or CC after cycloplegia with tropicamide.

Purpose: To verify the efficacy to obtain mydriasis and cardiovascular safety of Mydriasert (ophthalmic insert containing tropicamide and phenylephrine) in diabetic and nondiabetic patients undergoing retinal angiography by comparing it with usually administered eyedrops (tropicamide 1% and phenylephrine 10%)., Methods: This was a prospective randomized study. A total of 154 eyes of 77 patients were randomly divided into 2 groups: group 1 consisted of 78 eyes, group 2 consisted of 76 eyes, and the patients were monitored for pupillary dilation, blood pressure, heart rate, and possible adverse effects at 0, 20, 40, 60, and 90 minutes., Results: No severe adverse effects were observed in either group. In the entire sample studied, the mean pupillary diameter was greater in the eyedrops group after 20 and 40 minutes, while mydriasis was similar in the 2 groups after 60 minutes. The diabetic patients treated with Mydriasert had less mydriasis than those treated with eyedrops after 20 and 40 minutes, and diabetic patients showed less mydriasis than the nondiabetic patients after 60 and 90 minutes. There was no significant between-group difference in mean heart rate or systolic and diastolic blood pressure at any of the time points., Conclusions: Mydriasert assures an adequate degree of mydriasis for retinal angiography in both diabetic and nondiabetic patients. There are no differences in efficacy or safety between the insert and the usually administered eyedrops, but the low total drug dose administered with the insert reduces the risk of cardiovascular side effects.