412 NOTES, CASES, INSTRUMENTS

terior limiting membrane to be drawn up in the form of a cone.

For the next three weeks the eye became progressively more sensitive and a low-grade iritis continued. It, therefore, seemed necessary to attempt to sever the adhesion.

Using a small syringe and a hypodermic needle, air was injected into the anterior chamber in the following manner. The needle was introduced just anterior to the limbus and great care was taken to insure that the point did not touch the anterior limiting membrane of the vitreous.

Slight pressure was exerted on the plunger as the needle was pressed through the cornea. This enabled the operator to stop as soon as an air bubble appeared, thus as­suring that only the very tip of the needle had entered. Air was then injected until the eye was quite hard. A few moments later on examination, the adhesion was seen to be severed.

When the air had become absorbed a few days later, the vitreous was well in place; the anterior limiting membrane was intact and lying flat behind the pupil and the uveitis had subsided. When the patient was last seen, three months postoperatively, the eye was quiet and corrected vision was 20/25.

611 City Building.

A NEW SYNERGISTIC MYDRIATIC COMBINATION*

A PRELIMINARY REPORT

CARL REITER, M.D. Rockaway Park, New York

I was recently a member of a team as­signed to study, and, if possible, prevent the blindness so often associated with the in­cidence of retrolental fibroplasia in the pre­mature infant. This study entailed the care­ful and meticulous f unduscopic examination of many premature infants. The schedule in

* From the Department of Ophthalmology, The Jewish Hospital of Brooklyn.

a busy premature nursery would include examination of about six infants in one afternoon, of which about half would be reexaminations so necessary in a careful follow-up study.

At the beginning of this study it became apparent that the greatest difficulty to be sur­mounted was the uncertainty experienced in the use of the available mydriatics. Many pupils would not dilate, or dilatation would stop at half-mydriasis. In an attempt to sur­mount this difficulty combinations of mydri­atics were studied.

This is a preliminary report of a synergis-tic mydriatic combination that fulfills the fol­lowing criteria believed to be of importance in the routine funduscopic examination of premature infants: (1) Rapidity of action; (2) certainty of action; (3) active with deeply pigmented irises; (4) relatively short duration of action; (5) no undesirable sys­temic side reactions.

THEORY

Epinephrine substitutes are sympathomi-metic agents. The most important effect of these agents on the intraocular muscles are concerned with cells producing the effector substance in the iris dilator. This effect is reinforced by the ability of the same agents to affect cells in the opposing muscles which receive only inhibitor fibers from the sym­pathetic system. Thus, the iris sphincter partially relaxes under sympathetic stimula­tion, as does the ciliary muscle to a lesser ex­tent.

Phenylephrine hydrochloride (neosyn-ephrine hydrochloride) is stable for long periods even in high concentrations. The mydriasis produced is prompt and active and the effect on accommodation is definite but slight.1

Eucatropine hydrochloride is another drug classed as a sympathomimetic agent. The mode of action is different but it is synergis-tic to the epinephrine substitutes in that eucatropine (and cocaine) sensitizes the muscle cells to the action of sympathin and

NOTES, CASES, INSTRUMENTS 413

the epinephrinelike compounds. Moderately active mydriasis is produced with a slight decrease in accommodation. The duration of action is relatively brief.1

Theoretically, a mixture containing phenylephrine and eucatropine should be synergistic to a remarkable degree; eucatro­pine sensitizes the iris dilator to the action of phenylephrine.

To complete this synergistic mixture it was incorporated in a one-percent methyl-cellulose solution.2-3 This is a high viscosity, emollient solution, colorless and odorless, which mixes well with secretions. It spreads smoothly throughout the conjunctival sac.

The resultant mydriasis is smooth and uniform. The high viscosity properties of this substance enables the mydriatic mixture to remain in contact with the bulbar conjunc­tiva and cornea for a longer period of time. The instillation of eyedrops in infants is a difficult procedure to say the least. This high viscosity solution results in retention of medication in the conjunctival sac despite crying and the profuse production of tears.

M A T E R I A L S *

The mydriatic combination utilized con­tained five-percent phenylephrine hydro-chloride, five-percent eucatropine hydro-chloride, one-percent methyl cellulose, in a diluent of 0.45-percent sodium chloride. This solution remains stable for at least two months. Slight discoloration due to the oxi­dation of the phenylephrine does not detract from the mydriatic properties. Marked dis­coloration results in a highly irritating solu­tion, but does not occur before two months of storage. The presence of eucatropine ap­pears to preserve the phenylephrine, since

♦Kindly supplied by Robert S. Feinstein, 1315 48th Street, Brooklyn 19, New York.

similar solutions of phenylephrine without eucatropine become markedly discolored in about one month.

R E S U L T S

An unselected group of 75 premature in­fants was utilized. They varied in birth weight from 2.5 to 4.5 pounds. There were 20 Negro infants in the group. One drop of the mydriatic mixture was instilled by the ward nurse every 15 minutes for three doses. Maximal mydriasis was achieved in every case one-half hour following the third in­stillation. N o side reactions were observed. The duration of action varied between four to six hours. In almost every case the pupils were back to normal with good pupil­lary light reflexes in six hours.

Similar results were achieved in an un­selected group of 100 adults. In the average case, one drop of the mydriatic mixture gave maximal dilatation in one hour with the duration of action lasting four hours. No systemic or local side reactions were noted. There was no notable increase in intraocular pressure. The solution appears to be slightly less irritating than the 10-percent solution of phenylephrine hydrochloride in common use.

S U M M A R Y

A new synergistic mydriatic combination is presented which is of great value in the ophthalmoscopic study of the fundus oculi of the premature infant. It offers advantages unobtainable with the mydriatics now avail­able. Preliminary study disclosed the follow­ing advantages: rapidity and certainty of action with both deeply pigmented and non-pigmented irises, relatively short duration of action, and no undesirable systemic side reactions.

434 Beach 123 Street.

REFERENCES

1. Vail, D.: Gifford's Ocular Therapeutics. Philadelphia, Lea, 1947, pp. 4S-S4. 2. Swan, K. C.: Use of methyl cellulose in ophthalmology. Arch. Ophth., 33:378 (May) 1945. 3. ■ : Pharmacology and toxicology of the cornea. Arch. Ophth., 41:253 (Mar.) 1949.