Pseudophakic Pupillary Block Medication

Updated: May 02, 2018
  • Author: Mitchell V Gossman, MD; Chief Editor: Douglas R Lazzaro, MD, FAAO, FACS  more...
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Medication

Medication Summary

Patients with pseudophakic pupillary block may experience sudden and prolonged increases in IOP. As soon as the patient presents with this condition, the greatest concern is to lower IOP as quickly as possible. The near normalization of ocular tension reduces operative and postoperative risks. Almost all glaucoma medications may be used (see Glaucoma, Primary Open Angle), including beta-blockers and alpha2-agonists, but miotics should be avoided. In addition, acetazolamide (a carbonic anhydrase inhibitor) and mannitol (a hyperosmotic agent) may be required; analgesics and steroidal and nonsteroidal medicines also may be needed. Postoperative medicines depend on the progress; in most cases, it is the instillation of antibiotic-steroid and antiglaucoma drops.

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Carbonic anhydrase inhibitors

Class Summary

By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit carbonic anhydrase in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.

Acetazolamide (Diamox)

Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute angle-closure glaucoma when delay of surgery desired to lower IOP.

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Hyperosmotic agents

Class Summary

Hyperosmotic agents lower IOP by moving fluid out of the vitreous into the bloodstream. Cannot be used chronically due to the risk of dehydration and electrolyte imbalance (particularly hypokalemia). Mannitol is a highly effective medicine of this group. Given intravenously and highly suitable for patients with nausea and vomiting caused by severe rise in the IOP. Extremely useful for administration just prior to the surgery. Glycerine is a nontoxic, readily available hyperosmotic agent, to be administered by mouth, to tide over a period of crisis. Isosorbide is an important hyperosmotic agent that can be given safely to patients with diabetes.

Mannitol (Osmitrol, Resectisol)

For IV use, it is the first DOC, especially for preoperative use. Effective for a direct osmotic action, since it is distributed only in the extracellular space and penetrates very poorly in to the eye. The kidneys rapidly excrete it. Not metabolized and therefore suitable for patients with diabetes. DOC as hyperosmotic, for IV use. Adverse effects include urinary retention (due to excessive diuresis), headaches, back and chest pain, chills and rigors, nausea, vomiting, confusion, pulmonary edema, hypokalemia, and hyponatremia.

Glycerin (Ophthalgan, Osmoglyn)

Nontoxic drug absorbed rapidly after taking by mouth. Stable and easy to store. Has a very unpleasantly sweet taste. Frequently induces nausea and vomiting. Should be given chilled and flavored with lime powder or fruit juice over cracked ice. Metabolized, producing hyperglycemia; therefore, it is less suitable for patients with diabetes. Adverse effects include diarrhea, back pain, confusion, and hyperosmolar coma.

Isosorbide dinitrate (Ismotic)

Given by mouth, increases osmotic pressure of plasma in 2 ways. Before it is absorbed from the intestines, draws water in to intestines and causes hemoconcentration. Secondly, when it actually enters the blood, the osmolarity is increased. Tastes much better than glycerine. Not metabolized; therefore, suitable for patients with diabetes.

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Cholinergics

Class Summary

Help treat iris bombe by breaking iris IOL adhesions. Useful only in early cases. Once firm adhesions have been formed, it is difficult to break them by local medication.

Atropine ophthalmic (Atropair, Isopto, Atropisol)

Most potent parasympatholytic agent available. By paralyzing the sphincter pupillae muscle, helps dilate the pupil. Also paralyzes ciliary muscle. Effect lasts 7-10 days.

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Sympathomimetic agents

Class Summary

When combined with parasympatholytics, provide the best chance of dilating the pupil.

Phenylephrine ophthalmic (Neo-Synephrine)

Selective alpha1-agonist induces mydriasis and vasoconstriction and reduces IOP. Maximum effect is produced in 30 min and remains for several hours. Combined with anticholinergic drugs, produces maximal mydriasis.

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Corticosteroids

Class Summary

Inflammation is a constant accompaniment of patients with pseudophakic pupillary block. Steroid drops are very effective in reducing intensity of inflammation. Steroids control practically all aspects of the inflammatory process and immune response. Their main activity occurs at the actual site of inflammation; therefore, topical application in the eye suppresses inflammation.

Prednisolone acetate 1% (Pred Forte)

Most effective as anti-inflammatory agent on anterior segment of the eye. Frequent application needed to get maximal effect.

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