84 D. P. CHOYCE

When the lens is subluxated or dislocated, the enzyme, of course, achieves no useful purpose, merely digesting the face of the presenting vitreous or turning a subluxated lens into a dislocated one. Its use therefore is contraindicated in such cases.

There is much evidence to show that alpha chymotrypsin will exacerbate an early case of endothelial corneal dystrophy.

BORDERLINE CASES

1. In straightforward cases of senile cata­ract in the age group of 60 years and over, I do not think that the use of the enzyme makes much difference. I do, in fact, use it routinely in these cases, but only because it simplifies operating room procedure to have one technique which is used in almost all cataract cases, in preference to varying the method from case to case.

2. In the presence of posterior synechias, the enzyme will often fail, in spite of care­ful stripping of the adhesions from the lens capsule by a repositor before the enzyme is used. I find that the stripping process often weakens the capsule and that the enzyme subsequently completes the breach at the weakened points. Nevertheless, it is prob­ably worth trying the enzyme in these cases.

An ophthalmoscopic examination today is part of a complete physical examination and no longer the sole duty of the ophthalmolo­gist. Frequently, the general practitioner, the medical student, the interne and the intern-

* From the Wills Eye Hospital and the Graduate School of Medicine, University of Pennsylvania. Presented at the 14th annual Wills Hospital Clini­cal Conference, February, 1962.

CONCLUSIONS

1. The routine use of alpha chymotrypsin has led to a statistically significant increase in the percentage of "total" extractions in my practice from 83 to 96 percent.

2. The incidence of postoperative compli­cations shows certain beneficial tendencies which are not statistically significant.

3. The most important point in technique is that, when the enzyme is used, intraocular instrumentation can be reduced to a mini­mum. The use of the erisophake especially is contraindicated.

4. The enzyme is specially indicated in young patients with tough zonules in the age group 10 to 60 years, and in the presence of hypermature, swollen and intumescent cataracts at any age.

5. Its use is contraindicated in subjects under the age of 10 years (unless the lens is intumescent), or if the lens is already subluxated or dislocated.

6. On looking to the future the only res­ervation expressed concerns the later de­velopment of aphakic retinal detachment.

45 Wimpole Street (W. 1).

ist, inquires of the ophthalmologist, "What is a safe and good drug to use to obtain a good view of the fundus?" Many mydriatic agents are available for this purpose.

For an agent to be "good as well as safe," it should (1) produce rapid pupillary dila­tation, (2) be effective in the eyes of all patients, (3) be overcome rapidly and eas­ily, even if an acute rise in intraocular pres-

REFERENCES

Barraquer, J.: Communicacion a la real academia de medicina de Barcelona, April 8, 1958. Foster, J.: Ophthalmic Operation. Baillière, Tindall & Cox, 1961, p. 175. Vail, D.: The zonule of Zinn and the ligament of Wieger. Tr. Ophth. Soc. U. Kingdom, 77:441, 1957.

TROPICAMIDE: COMPARATIVE MYDRIATIC EFFECTS*

BERNARD C. GETTES, M.D. Philadelphia, Pennsylvania

TROPICAMIDE 85

sure is produced in patients with shallow anterior chambers and narrow chamber an­gles, and (4) should have little or no effect on accommodation, which means that phar­macologically the agent may be an adre-nergic or a parasympatholytic drug, or a combination of both.

Merrill, Goldberg, and Zavelle,1 Gettes2

and Gettes and Belmont3 reported on the use of tropicamidef as a cycloplegic and mydriatic agent. Gettes reported that one drop of the 0.5-percent solution was in­adequate for cycloplegia because the peak of paralysis of accommodation was of too brief duration but, because of the rapid return of the amplitude of accommodation for the patient to the predrop level, tropicamide ap­peared to be an effective mydriatic agent. Consequently, it was suggested that various concentrations and combinations of this agent be made available for clinical evalua­tion. The following solutions were then made available by the manufacturer: tropic­amide: 0.05, 0.1, 0.25, and 0.5 percent; 0.1-percent tropicamide in 1.0-percent hydroxy-amphetamine hydrobromide ; 0.1-percent tropicamide in 2.0-percent phenylephrine hydrochloride; 0.2-percent tropicamide in 2.0-percent phenylephrine hydrochloride ; 0.2-percent tropicamide in 1.0-percent hy-droxyamphetamine hydrobromide; and 0.3-percent tropicamide in 2.0-percent hydroxy-amphetamine hydrobromide.

METHODS OF STUDY As part of the complete ophthalmologic

examination, one drop of the solution being tested was instilled in one eye and a drop of another commonly used agent was in­stilled in the opposite eye. The patients were from the out-patient department and wards of the Wills Eye Hospital and from my private practice. The eyes of the patients were observed at 10, 20 and 30 minutes af­ter instillation. The amount of pupillary di­latation was not measured but the eyes were

t Tropicamide (Mydriacyl), Alcon Laboratories, Inc., Fort Worth, Texas.

compared to determine if pupillary dilata­tion was more rapid and more complete in one eye than in the other.

GROUP 1

In 50 patients, one drop of a solution of 0.05-percent tropicamide was instilled in the right eye and one drop of 4.0-percent co­caine hydrochloride was instilled in the left eye.

The amount of pupillary dilatation was approximately equal in each eye after 10, 20 and 30 minutes. The amount of dilatation was barely perceptible in the eyes of the Negro patients, minimal in eyes with brown irises and rarely more than five mm. in diameter in eyes with blue irises.

Conclusion. Neither agent is satisfactory for routine ophthalmoscopy.

GROUP 2

Fifty patients had a drop of the 0.1-per­cent tropicamide instilled in the right eye and one drop of 1.0-percent hydroxyamphet-amine hydrobromide in the left eye. After 20 minutes, the pupils of right (tropicamide eye) eyes with lightly pigmented irises were all more widely dilated. After 30 minutes, dilatation was approximately equal in all patients, but was less than five mm. in di­ameter in all of the eyes with darkly pig­mented irises. In the patients with lightly pigmented irises, those eyes with the tropic­amide displayed more effective mydriasis.

GROUP 3

In 50 patients, one drop of 0.1-percent tropicamide was instilled in the right eye and one drop of 3.0-percent hydroxyamphet-amine hydrobromide in the left eye. Dilata­tion was approximately equal after 10, 20 and 30 minutes. The pupillary diameters were less than five mm. in most of the Negro patients.

Conclusion. One drop of 0.1-percent trop­icamide, 1.0-percent hydroxamphetamine and 3.0-percent hydroxyamphetamine is ade­quate in most white patients for pupillary

86 BERNARD C. GETTES

dilatation for routine ophthalmoscopy but is not recommended for indirect ophthalmos­copy.

GROUP 4

Fifty patients had one drop of 0.25-per­cent tropicamide instilled in the right eye and one drop of 10-percent phenylephrine instilled in the left eye.

The amount of dilatation of the pupil was approximately equal in all patients after 10, 20 and 30 minutes. After 20 minutes, dila­tation was more than five mm. in all but six Negroes. After 30 minutes, dilatation was more than five mm. and approximately equal in all but the Negro patients. The right (tropicamide) eyes showed less fre­quent reaction to bright light, as is ordinar­ily utilized with indirect ophthalmoscopy.

Conclusion. One drop of 0.25-percent tropicamide and one drop of 10-percent phenylephrine are satisfactory agents for routine ophthalmoscopy.

GROUP 5

In 50 patients, 0.5-percent tropicamide was instilled in the right eye, and 10-percent phenylephrine was instilled in the left eye.

Pupillary dilatation was more marked in all right eyes after 10 minutes but was equal in all but eight patients after 20 minutes. The right eye always exhibited greater mydriasis in these cases. After 30 minutes, the amount of mydriasis was approximately equal in all patients. An occasional patient showed a slight reaction to bright light in the eye with phenylephrine.

Conclusion. Use of 0.5-percent tropica­mide is adequate for routine indirect oph­thalmoscopy with the binocular ophthalmo­scope.

GROUP 6

In another group of patients, 0.2-percent tropicamide in a solution of 2.0-percent phenylephrine was instilled in the right eye and compared with 10-percent phenyl­ephrine in the left eye.

The right eyes exhibited greater mydriasis after 10 and 20 minutes.

Conclusion. This combination is adequate for indirect ophthalmoscopy.

Since the amount of mydriasis elicited with 0.25-percent tropicamide, 0.5-percent tropicamide and 0.2-percent tropicamide with 2.0-percent phenylephrine is rarely required except where indirect ophthalmos­copy is performed, the risk of precipitating an episode of acute narrow-angle glaucoma appears great. Such a crisis was not produced in any of these patients. It was, therefore, decided to compare the effects of 0.1-percent tropicamide in a solution of 1.0-percent hydroxyamphetamine, and 0.1-per­cent tropicamide in a solution of 2.0-percent phenylephrine.

GROUP 7

One drop of the 0.1-percent tropicamide with 1.0-percent hydroxyamphetamine was instilled into the right eyes of 100 consecu­tive patients, and 0.1-percent tropicamide with 2.0-percent phenylephrine was instilled into the left eyes.

The amount of pupillary dilatation was greater in the right eyes of all patients after 10 and 20 minutes. Dilatation was five mm. or more after 20 minutes and equal in all pa­tients after 30 minutes. Pupillary dilatation was approximately equal in all but 11 patients and, in these 11 patients, the degree of mydriasis was always greater in the right eye. The intraocular pressure rose to 28 to 35 mm. Hg (Schijzitz) in both eyes of three patients. Pupillary dilatation was overcome and the tension dropped to 22 mm. Hg or less (Schlitz) within 30 minutes after the instillation of 2.0-percent pilocarpine in all three cases.

Conclusion. Both combinations are ade­quate for routine ophthalmoscopic examina­tion.

The combination of 0.1-percent tropica­mide with 1.0-percent hydroxyamphetamine appears to be more effective than the com­bination of 0.1-percent tropicamide with 2.0-percent phenylephrine.

TROPICAMIDE 87

Since pupillary dilatation is greater than five mm. with the 0.1-percent combinations, it was concluded that the combinations uti­lizing the 0.2-percent and the 0.3-percent solutions of tropicamide were unnecessary for routine ophthalmoscopy.

In addition to these controlled groups, various concentrations of tropicamide from 0.1, 0.25, 0.5, and 1.0-percent, as well as combinations of tropicamide with the ad-renergic agents, have been used in hundreds of additional patients. It is noteworthy that, after one year, only two episodes of acute angle block were precipitated in patients who were thought to have open angles. This occurred after the instillation of 0.5-percent tropicamide. In one case the tension was re­stored to normal levels with a course of mecholyl and prostigmin. The second patient required a second course of mecholyl and prostigmin in one eye.

To summarize: 0.05-percent tropicamide is as ineffective as 4.0-percent cocaine hydro-chloride; 0.1-percent tropicamide is more effective than 1.0-percent hydroxyampheta-mine; 0.1-percent tropicamide is as effective as 3.0-percent hydroxamphetamine ; 0.25-per­cent tropicamide is as effective as 10-percent phenylephrine; 0.5-percent tropicamide is

Double elevator paralysis is a syndrome in which the superior rectus and the in­ferior oblique muscles of the same eye are paralyzed, affecting the upward movements in the involved eye. The paralysis may vary from subtotal to total. Usually, the inferior

* From the Department of Ophthalmology, West­ern Reserve University.

more effective than 10-percent phenylephrine ; 0.2-percent tropicamide with 2.0-percent phenylephrine is more effective than 10-per­cent phenylephrine; 0.2-percent tropicamide with 1.0-percent hydroxyamphetamine is more effective than 10-percent phenyl­ephrine; 0.1-percent tropicamide with 1.0-percent hydroxyamphetamine is more effec­tive than 0.1-percent tropicamide with 2.0-percent phenylephrine.

CONCLUSIONS

The combination of 0.1-percent tropica­mide with 1.0-percent hydroxyamphetamine is an effective mydriatic agent. Its effect is rapid and it is easily overcome. It is recom­mended for routine ophthalmoscopic ex­amination for both the ophthalmologist and the internist, as well as the general practi­tioner.

For indirect ophthalmoscopy with the binocular ophthalmoscope, the 0.5-percent and the 1.0-percent solutions of tropicamide are recommended. It is further recommended that 10-percent phenylephrine be addition­ally instilled in the eyes with darkly pig-mented irises for this type of examination.

1930 Chestnut Street (3).

oblique is more involved.1 There may also be an associated paralysis of the other ocu­lar muscles, particularly the levator pal-pebrae involvement of which results in ptosis.

According to Chavasse,2 this syndrome with total paralysis of both muscles is quite rare. Bielschowsky3 stated that isolated

REFERENCES

1. Merrill, D. L., Goldberg, B., and Zavelle, S.: Bis-Tropamide: A new parasympatholytic. Current Therap. Res., 12:43, 1960.

2. Gettes, B. C: Tropicamide: A new cycloplegic mydriatic. Arch. Ophth., 65:48, 1961. 3. Gettes, B. C, and Belmont, Owen: Tropicamide comparative cycloplegic effect. Arch. Ophth., 66:

336, 1961.

DOUBLE ELEVATOR PARALYSIS*

ROBERT S. ROSNER, M.D. Cleveland, Ohio